Feature

In October 2000, 35-year-old Doug Davidson was on vacation in Tunica, Miss., when he collapsed to a casino floor. Paramedics rushed him to the hospital, where doctors discovered he'd suffered a massive brain hemorrhage. After 10 days in a coma, he awoke-but the formerly fit butcher was unable to speak or walk.

Davidson's sister, Sherri Scherf, knew that her brother faced a long road of rehabilitation. She also knew that if possible, she wanted Davidson-a bachelor with elderly parents-to live with her and her family rather than in a nursing home.

But Scherf's home, where she homeschooled her four young children, sat on a remote seven-and-a-half acres 40 minutes outside of Oklahoma City. The prospect of driving Davidson into the city many times each week for his various appointments-including ones with a speech pathologist, occupational therapist and physical therapist-was daunting.

When Scherf called the Integris Jim Thorpe Rehabilitation Hospital in Oklahoma City to explain her problem, rehabilitation psychologist Pamela Forducey, PhD, proposed a solution. Davidson, Forducey said, was an ideal candidate to participate in the center's new telehealth rehabilitation program.

Forducey and the rehabilitation team visited Davidson to evaluate his condition and needs in person. Then the team worked with Scherf and Davidson via weekly videophone sessions, with the therapists directing Scherf as she helped her brother through his speech, physical and occupational therapy. Forducey also provided family counseling via videophone to help Scherf and her family with the stresses they faced as caregivers. Integris Health, which is a private, nonprofit hospital system, provided the family with the videophone hookup in their home.

By the time the six-month pilot project finished, Davidson was able to walk to the end of the family's quarter-mile driveway, prepare a bowl of cereal and count aloud to 30.

"It was important to my husband and me not to change our children's lives and schedules too much," Scherf says. "This allowed me to stay at home and be a mom and homeschool my children."

Forducey, the director of Integris's telehealth network, says that telehealth is ideal for circumstances like Scherf and Davidson's.

"The main thing I want to do is make sure that folks with injury have access to the health professionals they need, regardless of their distance from a medical center," she says.

Her program at Integris Health is one of many around the country that have, in the past decade or so, begun to explore the possibility of using technology-from videophones to the Internet-to provide rehabilitation services to patients who otherwise might have trouble accessing them. The movement is part of a much larger telehealth trend of providers using technology to provide access to specialty mental health services to the 60 million Americans who live in rural areas, where those specialties often don't exist.

Telehealth has been around in some form since the 1960s, but it really took off in the 1990s with the advent of the Internet and advanced videophone technology. By 1999, approximately 100 telehealth networks around the country provided direct patient care at thousands of sites, a survey by the American Telemedicine Association found.

These programs have generally been successful, with controlled studies finding patient outcomes as good as those of traditional rehabilitation therapy.

Video connections

Doug Davidson is one of at least 9,000 patients for whom Forducey has set up telerehabilitation programs over the past seven years. In one study that looked at mental health outcomes among first-time stroke patients, she and her colleagues compared patients who received home-based physical and occupational therapy via videophones with patients who received traditional face-to-face home health service visits from physical and occupational therapists. They found that after the interventions, the telerehabilitation patients and the traditional patients did not differ in their levels of depression or their scores on the Mental Component Summary Scale, a scale of overall mental functioning.

And in a case study of one of the telerehabilitation patients that the researchers published in Neurology Report (Vol. 26, No. 2, pages 87-93), they estimated that in addition to saving the patient, caregiver and therapists time, the program saved the state more than $8,000 in reduced travel costs.

Such findings may help sway insurers to pay for telehealth services more often, Forducey suggests. Reimbursement remains a stumbling block for some psychologists who would like to take advantage of telehealth applications: In 2001 Medicare decided to reimburse for telehealth mental health services, but attached many restrictions about the types of technology allowed and the sites at which the services could take place. And, of course, private insurers are free to decide on their own which services to reimburse.

Meanwhile, some psychologists are using telehealth video conferencing not to meet directly with rehabilitation patients, but instead to train other psychologists to provide services.

Psychologist Laura Schopp, PhD, and her colleagues at the University of Missouri used videoconferencing to train rural mental health providers-usually psychologists, sometimes social workers-to help patients with traumatic brain injuries who live in rural areas.

The clinicians received up to six hours of one-on-one training via videophone with a neuropsychologist, learning about everything from the impact of brain injury on emotional and behavioral functioning to the neuropathology of brain injury, and the neuropsychologists remained available for follow-up videophone consultations.

In a review of the project published last April in Professional Psychology: Research and Practice (Vol. 36, No. 2, pages 158-163), Schopp and her colleagues found that patients who saw the specially trained clinicians rated them as more knowledgeable, and generally found therapy more helpful, than patients who saw local clinicians who had not participated in the training.

"We used to send our patients home to absolutely no services," Schopp says. "This is a way to change that."

Internet applications

Videoconferencing works well for one-on-one interactions, but for connecting large groups of people the Internet is ideal, says University of Pittsburgh neuropsychologist Joseph Ricker, PhD. He and fellow Pitt researchers are examining the feasibility of using the Internet to provide services and support to traumatic brain injury patients and their families.

The work began four years ago with a simple survey to evaluate brain injured patients' access to and use of computers.

"Telerehab using computers is only going to work if people have access to computers, pre-injury experience with computers and willingness to use them," Ricker says.

He surveyed 71 patients, all of whom had sustained serious injuries with lasting cognitive effects. In the results of the survey, published in the Journal of Head Trauma Rehabilitation (Vol. 17, No. 3, pages 242-250), Ricker found that nearly 90 percent of the patients had used a computer at some point in the past and nearly 60 percent still used one regularly. More than 70 percent of the computer users said that they would be likely to use an Internet-based service that would provide help with aspects of daily living, such as practice using automated teller machines and exercises to improve memory. And more than 50 percent said that they would be likely to use an Internet service that provided information about brain injury-specific community resources.

In a way, it's not surprising that the percentages of computer users were so high, Ricker says. In general, brain injury patients tend to be relatively young-the average age of his participants was 37.

"It may be a while down the road before something like this is widespread," Ricker says, but he thinks his results show that it is feasible.

In the meantime, Ricker's colleague Armando Rotondi, PhD, a health policy professor at the University of Pittsburgh, has been investigating using the Internet to provide support to the caregivers of patients with traumatic brain injury.

Research has shown, he says, that patients with chronic illnesses fare better when their caregivers are less stressed. Support groups can provide an outlet to relieve stress and solve problems, but people in rural areas often find it difficult to find and attend group meetings.

Rotondi recruited 17 caregivers to take part in his study. He provided a computer and Internet access to those who needed them, and set up a Web site that included general resources and information about brain injury, as well as a bulletin-board style support group moderated by a psychologist. In an evaluation of the project published in 2005 in the Journal of Head Trauma Rehabilitation (Vol. 20, No. 2, pages 145-157), Rotondi found that, on average, the participants accessed the site more than 800 times over the course of six months, and most found it both easy to use and helpful.

Overall, then, says Forducey, telehealth technologies are simply a way to provide patients and family members who are isolated-either by geography or circumstances-with the best possible care.

"We're giving folks less time in the hospital now," she says, "so it's crucial that when they go home they have access to the support they need."