Abstract
Gait and mobility aid assessments are important components of rehabilitation. Given the increasing use of telehealth to meet rehabilitation needs, it is important to examine the feasibility of such assessments within the constraints of telerehabilitation.
The objective of this study was to examine the reliability and validity of the Tinetti Performance-Oriented Mobility Assessment gait scale (POMA-G) and cane height assessment under various video and transmission settings to demonstrate the feasibility of teleassessment.
This repeated-measures study compared the test performances of in-person, slow motion (SM) review, and normal-speed (NS) video ratings at various fixed frame rates (8, 15, and 30 frames per second) and bandwidth (128, 384, and 768 kB/s) configurations.
Overall bias, validity, and interrater reliability were assessed for in-person, SM video, and NS video ratings, with SM video rating as the gold standard, as well as for different frame rate and bandwidth configurations within NS videos.
There was moderate to good interrater reliability for the POMA-G (intraclass correlation coefficient [ICC] = 0.66–0.77 across all configurations) and moderate validity for in-person (β = 0.62; 95% confidence interval [CI] = 0.37–0.87) and NS video (β = 0.74; 95% CI = 0.67–0.80) ratings compared with the SM video rating. For cane height, interrater reliability was good (ICC = 0.66–0.77), although it was significantly lower at the lowest frame rate (8 frames per second) (ICC = 0.66; 95% CI = 0.54–0.76) and bandwidth (128 kB/s) (ICC = 0.69; 95% CI = 0.57–0.78) configurations. Validity for cane height was good for both in-person (β = 0.80; 95% CI = 0.62–0.98) and NS video (β = 0.86; 95% CI = 0.81–0.90) ratings compared with SM video rating.
Some lower frame rate and bandwidth configurations may limit the reliability of remote cane height assessments.
Teleassessment for POMA-G and cane height using typically available internet and video quality is feasible, valid, and reliable.
Restoration of gait and mobility functions is an important aim in rehabilitation as it contributes towards making an individual functionally independent. Individuals who regain mobility experience improve quality of life and lower risk of downstream complications compared with individuals with lower mobility. Therefore, accurate assessment of gait and mobility performance and fitting of mobility aids are integral components of most rehabilitation interventions.
Although formal gait analysis using motion-capture systems is the gold standard for evaluating gait and mobility performance, such analysis is expensive and requires a specialized laboratory setup that may not be feasible or practicable for clinical or home settings. Several simpler gait performance assessment scales have therefore been developed to meet clinical needs in rehabilitation care. Of these, one of the most commonly used is the Tinetti Performance-Oriented Mobility Assessment (POMA) gait scale (POMA-G), developed in 1986, to reliably assess gait functions in older adults with minimal equipment and training, along with a corresponding balance scale.1 The POMA-G tests both gross motor coordination and awareness of spatial relationships during movement and is one of the few qualitative rather than timed measures of gait. The POMA has been used extensively in studies in older populations2,3 and also in other diseases, such as Parkinson’s disease, stroke, and orthopedic conditions.4,5
Canes are one of the most common walking aids prescribed for people with ambulation impairments to improve gait safety and reduce falling. Therapists routinely adjust mobility aids relative to the patient’s height to optimize body mechanics and ensure that the patient’s center of gravity remains over their base of support when using the mobility device. Ideally, cane height should be measured from the floor to the distal wrist crease.6 Fitting cane height therefore also requires accurate assessment of spatial relationships.
Traditional practice requires the in-person assessment of gait and fitting of mobility aid in the clinic setting.4,7 However, rehabilitation services are increasingly offered remotely to meet the needs of persons living in remote locations, enable greater efficiency in provision of health care services, and overcome manpower resource constraints.8–10 Such telerehabilitation interventions have been demonstrated to achieve outcomes as good as or better than traditional rehabilitation interventions in patients with stroke or other neurological and orthopedic conditions.11–13 However, even in these telerehabilitation setups, the bulk of gait and mobility assessment still occurs face to face, in part because providers may lack confidence in the reliability and validity of such assessments using video technology.14
In recent years, there have been efforts to develop teleassessment technologies for remote assessment of functional tests, such as the Six-Meter Walk Test, Timed “Up & Go” Test, Five Times Sit-to-Stand Test, and Balance and Forward Reach Test.15–18 However, these attempts have used additional equipment like accelerometers,15,18 inclinometers,17 specially designed sensors,16 and computer systems with specialized software.15–18 In addition, these previous initiatives have involved synchronous data transmission, where data are transferred in real-time between devices, allowing for 2-way communication. Although synchronous transmission allows for fast and efficient data transfers, it is expensive and requires reliable high-speed internet connectivity. The requirements for high-end technology and high-speed internet connections hinder the reach of teleassessment and telerehabilitation to remote rural communities that need these services the most and where technological infrastructure available for telehealth is limited.19,20 Therefore, it is important to examine the feasibility, reliability, and validity of administering and evaluating commonly used tests like POMA-G and cane height assessment within the constraints of the usual telerehabilitation setups, which typically have low bandwidth and internet speed connections. Synchronous transmission of large amounts of data may not be feasible with such set ups, and asynchronous transmission, where data are first stored locally and subsequently forwarded to the receiving device, may be preferred. Figure 1 depicts these 2 different modes of transmission as they might occur using standard Veterans Affairs (VA) telehealth technology.
Figure 1. Veterans Affairs TeleHealth Technology setup.
We previously reported that the loss of resolution and reduction in number of frames transmitted per minute because of low bandwidth conditions resulted in the reduction of test validity and reliability when assessing gross and fine motor movements.21–23 Therefore, in this study, we also examined the reliability and validity of standardized observational gait evaluation (POMA-G) and cane height assessment under various asynchronous video and transmission settings to assess their feasibility for use in remote teleassessment. If these tests can be shown to be reliable and valid under a range of video and transmission settings, the rehabilitation community would be enabled to conduct such assessments remotely, using either asynchronous (ie, store and forward videos) or synchronous (ie, live 2-way video) methods for telerehabilitation.
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