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journal_c_article_2.pdf

Comparison of Functional Outcomes and Treatment Cost Between a Computer-Based Cognitive Rehabilitation Teletherapy Program

and a Face-to-Face Rehabilitation Program

Mike R. Schoenberg University Hospitals Case Medical Center

William D. Ruwe NeuroResources PLLC and University of Oklahoma Health

Sciences Center

Kyra Dawson Cleveland State University

Nicholas B. McDonald, Beki Houston, and Pamela G. Forducey

INTEGRIS Jim Thorpe Rehabilitation Center

The authors compared outcomes of 19 participants who received computer-based cognitive teletherapy rehabilitation with 20 participants who received face-to-face speech–language rehabilitation. The study compared outcomes from 2 “real-word” treatment programs provided by an outpatient rehabilitation center. A total of 39 participants with moderate to severe closed head traumatic brain injuries and a minimum of 1 year following injury were analyzed. Outcome measures included clinical indicators of independent living status, return to work or school, and independent driving. Cost measures included the total cost of the treatment and a measure of service costs per hour. Time since injury was a covariate, and an analysis of covariance revealed no differences between groups in independent living, driving status, return to work or school, or total treatment costs. The computer-based teletherapy cognitive rehabilitation program provided similar functional outcomes as face-to-face speech–language therapy at a similar total cost.

Keywords: cognitive rehabilitation, telemedicine, teletherapy, traumatic brain injury

Acquired brain injuries can produce physical, emotional, and cognitive deficits (National Academy of Neuropsychology, 2002).

Estimates suggest that more than 1.5 million Americans survive a traumatic brain injury (TBI) each year, and many of these are

MIKE R. SCHOENBERG received his PhD in clinical– community psychol- ogy, clinical program from Wichita State University. He is a diplomate of the American Board of Professional Psychology in clinical neuropsychol- ogy by the American Board of Clinical Neuropsychology. He is an assis- tant professor in the Department of Neurology, University Hospitals Case Medical Center. Areas of research include diagnostic and ecological va- lidity of neuropsychological tests, neuropsychological effects of epilepsy, neurodegenerative disorders, mild cognitive impairment, neuropsychiatric disorders, stroke, traumatic brain injury, cognitive rehabilitation, psycho- pharmacology, the anatomical correlates of learning and memory, and forensic neuropsychology. WILLIAM D. RUWE received his PsyD in clinical psychology from George Fox University and his PhD in neurobiology from Purdue University. He is owner of NeuroResources, PLLC, an independent practice clinic specializing in neuropsychological services. He is a clinical associate professor at the Uni- versity of Oklahoma Health Sciences Center. He also serves on the Clinical Training Committee of the internship training program with the Oklahoma Health Consortium. His areas of professional interest include traumatic brain injury, dementia, neurocognitive sequelae of neurological disorders, cognitive rehabilitation, and forensic neuropsychology. KYRA DAWSON received her MA in clinical psychology from Cleveland State University. She is currently a DO/PhD student at Ohio University. Her re- search interests are the validity of neuropsychological tests across populations, psychopharmacology, and the behavioral and cognitive effects of epilepsy. NICHOLAS B. MCDONALD received his PhD in experimental psychology from the University of Oklahoma. He is a senior research associate for the

American Education Corporation. Areas of professional interest include anxiety and trauma, educational issues, interpersonal attraction, group cohesion, neurological correlates of learning and memory, and human social behavior. BEKI HOUSTON received her MA in communication sciences and disorders from Oklahoma State University. She is a speech–language pathologist at INTEGRIS Hospital in Oklahoma City. She provides speech–language ser- vices to children and adults in rural Oklahoma communities via telemedicine. PAMELA G. FORDUCEY received her PhD in counseling psychology from the University of Oklahoma in 1989. She is board certified by the American Board of Professional Psychology in rehabilitation psychology. She is the director of INTEGRIS Telehealth and the Neuroscience Institute at INTE- GRIS Southwest Medical Center in Oklahoma City. She has 16 years of clinical and administrative experience working with individuals with dis- abilities and their families. The second half of her career has been focused on increasing access to health care via telecommunications technology for individuals with chronic medical conditions who reside in rural areas of Oklahoma. THE AUTHORS DO NOT HAVE A FINANCIAL INTEREST in the commercially available product described in this article, CSI, or Psychological Software Services PSS CogRehab Version 95. However, William D. Ruwe is an unpaid consultant for CSI. CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Mike R. Schoenberg, Department of Neurology, University Hospitals Case Med- ical Center, HH 5, 11100 Euclid Avenue, Cleveland, OH 44106-5000. E-mail: [email protected]

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discharged home with TBI-related disabilities (Sosin, Sniezek, & Thurman, 1996). On the basis of 1985 data, it has been estimated the total lifetime cost of head injuries in the United States was $4.5 billion, of which $3.5 billion was related to hospital costs alone (Max, MacKenzie, & Rice, 1991). A study from 1997 to 1999 reported an annual cost for TBI of $3 billion for inpatient costs alone (McGarry et al., 2002). As the cost of health care escalates, it is important to explore treatment modalities for these individuals that will both increase quality of life and enhance cost efficiency.

Cognitive rehabilitation provides a “systematic, functionally- oriented service of therapeutic cognitive activities, based on an assessment and understanding of the person’s brain-behavior def- icits” (Harley et al., 1992, p. 63). Whereas some view cognitive rehabilitation as a luxury (Phipps & Allman, 1999), face-to-face forms of speech–language cognitive rehabilitation have demon- strated efficacy in improving the cognitive functioning of patients (Cicerone, 1999; Cicerone et al., 2000). Training in individual compensatory strategies for neurological deficits has improved the functional ability of persons with brain injury, especially when psychological and other problems are treated concurrently as part of a holistic approach (Carney et al., 1999; Prigatano, 1999). Cognitive rehabilitation services are intensive and typically deliv- ered in ambulatory clinics using a face-to-face modality; however, more cost-effective cognitive rehabilitation methods are sought to improve health care delivery (Ricker, 1998).

Telemedicine offers an innovative method for the delivery of therapeutic services to rural populations. Telemedicine uses com- puter and phone technology to provide health care services rather than through the traditional face-to-face interaction (Winters, 2002). The benefits of telemedicine include greater continuity of care, increased access to medical care, decreased travel time, and a potential reduction in health care costs (Hailey, Roine, & Ohin- maa, 2002; Roine, Ohinmaa, & Hailey, 2001). Telemedicine has been used successfully to increase health care access for a variety of patient groups in underserved areas (e.g., Burns et al., 1998; Clark, Dawson, Scheideman-Miller, & Post, 2002; Conrad, 1998; Day & Schneider, 2002; Fitzgerald, Yee, Geobert, & Okamoto, 1992; Popescu, Burdea, Bouzit, & Hentz, 2000; Riva & Gam- berini, 2000; Schopp, Johnstone, & Merrell, 2000; Woods, Kutlar, Grigsby, Adams, & Stachura, 1998). Although telemedicine pro- grams have traditionally focused on monitoring patient health status (Woods et al., 1998) or supplementing physical rehabilita- tion and the use of assistant devices (Burns et al., 1998; Popescu et al., 2000), experts have successfully implemented telemedicine programs to provide stroke rehabilitation (Clark et al., 2002), neuropsychological screening (Schopp et al., 2000), and cognitive therapy (Day & Schneider, 2002). A telemedicine program pro- viding psychological or rehabilitation services has been termed teletherapy. Preliminary data for teletherapy programs have dem- onstrated similar outcomes and patient satisfaction when compared with face-to-face services (Brown et al., 1999; Day & Schneider, 2002; Mair & Whitten, 2000; Schopp et al., 2000). However, lack of familiarity with existing methods, emerging treatment pro- grams, unknown reimbursement, and unknown cost– benefit ratios have slowed the implementation of teletherapy (Lacroix et al., 2002; Mair & Whitten, 2000; Salvatore, 2002; Sjogren, Tornqvist, Schwieler, & Karlsson, 2001).

The purpose of this study was to compare outcomes between participants receiving a “real-world,” commercially available

computer-based cognitive rehabilitation teletherapy program and patients receiving “real-world,” nonresearch face-to-face outpa- tient speech–language therapy. Outcome variables included mea- sures of functional independence (independent driving, living, etc.) and treatment cost. Within an analysis of “real-world” treatments, we expected that participants receiving teletherapy would have similar outcomes to participants receiving outpatient speech– language treatment at equal or reduced costs.

Method

Participants

The sample included participants who had sustained moderate to severe closed head TBIs and were residing in the state of Okla- homa. Participant data were collected from a retrospective chart review from a large rehabilitation hospital in Oklahoma. Partici- pants were asked to participate in a teletherapy (TELE) program and were not randomly assigned because of concerns of maintain- ing treatment fidelity. The TELE group included 20 consecutive participants who began a computer-based cognitive rehabilitation program via computers connected to the Internet at their home. One participant in the TELE group discontinued the computer- based program following enrollment and was removed from the study (n � 19). A separate group of 20 participants with moderate to severe closed head TBI who each received a minimum of six sessions of face-to-face outpatient speech–language rehabilitation therapy served as the face-to-face (FTF) reference group. Partici- pants in the FTF group were selected from a larger sample of patients who received outpatient face-to-face rehabilitation ser- vices to match the TELE group participants in age, education, gender, hand dominance, and level of functioning. Selection of all participants was blinded to the dependent variables. All partici- pants received face-to-face therapy during their acute hospitaliza- tion period as medically indicated. Participants were excluded if they had sustained a subsequent head injury (or major medical illness), received additional therapeutic services during the study, or were so impaired that they could not understand or complete basic rehabilitation exercises. Participants did not receive addi- tional outpatient speech–language, occupational, or vocational therapy during the study. Participants continued to receive routine medical care. Prior to initiating either type of outpatient therapy for the study, participants completed a comprehensive neuropsycho- logical evaluation, including measures of general cognitive func- tioning (e.g., Wechsler Abbreviated Scale of Intelligence [WASI]; Psychological Corporation, 1999; or Wechsler Adult Intelligence Scale—Revised [WAIS–R]; Wechsler, 1981) and memory (e.g., Wechsler Memory Scale—Revised [WMS–R]; Wechsler, 1987).

Measures

Demographics. The participant’s gender, age, years of educa- tion, dominant hand, months since injury, type of injury, and the severity of head injury were obtained from medical records and are presented in Table 1. A majority of participants completed the WASI and WMS–R, and the means and standard deviations for the WASI Full-4 Index scores and WMS–R memory and attention indices for this subsample of participants are presented in Table 1.

Type of therapy. Two types of cognitive rehabilitation were compared: The TELE group received a form of cognitive rehabil-

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itation that used a series of computer exercises delivered to par- ticipants in their homes over the Internet under the supervision of a licensed rehabilitation therapist. The rehabilitation therapy exer- cises were provided by Cognitive Systems Incorporated (CSI) and are marketed as the CRI/PSS Teletherapy System. The treatment program originally was designed by Chen, Thomas, Glueckauf, and Bracy (1997) and marketed as Psychological Software Ser- vices PSS CogRehab Version 95. The exercises were designed to enhance cognitive functioning in several domains, including sim- ple attention, reaction time (e.g., Simple Auditory and Simple Visual Reaction), visuospatial skills (e.g., Cube-In-A-Box, Mazes), learning and memory (e.g., Sequenced Recall, The Phone Message), and problem solving (e.g., Number Manipulations, Maze Puzzle, Pyramids). The rehabilitation program was designed to meet the needs of each participant and was guided by a pre- treatment neuropsychological evaluation. Initially, the intervention was directed toward foundational skills and then increased toward more complex processing and reasoning tasks dependent on the progress of the participant and the judgment of the therapist. A dedicated system, which was installed on a personal computer, was placed in each participant’s home for the duration of the therapeu- tic intervention, and a technician established the Internet connec- tions. The software, computer, and Internet connection were part of the program. A total of four therapists provided teletherapy. The therapists providing teletherapy were all master’s-level trained professionals who were certified speech–language pathologists and had been certified in the Chen et al. teletherapy program.

The teletherapy procedure initially involved a therapist meeting with the subject face-to-face to introduce the system, including the

hardware configuration and the software package. Each participant had one therapist. After ensuring that the participant was familiar with the system, the remaining interventions were completed using a client–server computerized interface system with remote access via the Internet. At their convenience, participants dialed the CRI/PSS Teletherapy server, downloaded the prescribed program, and initiated the therapy exercises. There was no additional cost for each time participants logged on to the system. After complet- ing the prescribed exercises, the encrypted data from the partici- pants were sent via the Internet to the server, which was accessed on a regular basis by the therapist. The therapist monitored par- ticipants’ progress closely, and the exercises were adjusted on the basis of each participant’s performance on the prescribed tasks. The therapist made adjustments to the program and uploaded these changes to the server.

Face-to-face rehabilitation was a programmatic outpatient speech and cognitive therapy program delivered in a face-to-face manner by certified and licensed speech–language therapists who had a minimum of 10 years’ experience (see Procedure for de- tailed description).

Dependent variables. Cost of treatment and self-reported hours of treatment were compared. Functional outcome variables of treatment included independent living, independent driving, and return to work or school (see Table 2).

Costs of treatment in the TELE group included (a) rental of the computer equipment, (b) Internet connection fees, (c) all charges associated with the configuration of the computer equipment, and (d) cost of teletherapist personnel time to program and evaluate participants’ progress in teletherapy. The teletherapy costs did not

Table 1 Demographics by Therapy Group

Variable

TELE (n � 19) FTF (n � 20)

pM SD n M SD n

Age (years) 27.4 9.08 33.1 16.38 ns Education (years) 12.0 2.94 11.4 2.66 ns Months postinjury 58.7 55.98 29.4 22.53 .037 Log10 of months postinjury 1.62 0.36 1.41 0.21 .030 Gender ns

Male 18 15 Female 1 5

Dominant hand ns Right 19 13 Left 0 2 Both 0 1

Weeks in therapy 24.4 19.36 9.8 7.94 .004 Hours of therapy* 95.84a 66.46a 27.05b 24.22b �.001 Total cost of treatment 3,672.00 4,739.38 2,610.48 1,780.90 ns Cost per hour* 58.87a 53.89a 103.74b 16.74b .003 WASI Full-4 Index score 89.78 16.94 9 90.92 17.35 12 ns WMS–R General Memory 93.36 21.24 14 85.33 16.91 12 ns WMS–R Delayed Memory 84.93 24.59 14 84.83 18.89 12 ns WMS–R

Attention/Concentration 91.93 20.85 14 85.83 14.56 12 ns

Note. TELE � participant group receiving computer-based teletherapy services; FTF � participant group receiving face-to-face speech–language therapy services; WASI � Wechsler Abbreviated Scale of Intelligence administered prior to participant starting study treatment; WMS–R � Wechsler Memory Scale—Revised administered prior to participant starting study. * Hours of therapy were calculated differently: a Based on participant self-report. b Hours of face-to-face treatment was based on review of medical records.

171COMPUTER-BASED TELETHERAPY

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incorporate electric utility fees for the operation of the computer. The face-to-face therapy cost was limited to the billed time and did not include the participant’s costs for transportation to and from the outpatient rehabilitation office, because efforts to estimate costs varied significantly because of variations in car types (i.e., car, truck, or public transportation) and the distance participants traveled.

Procedure

All FTF speech–language pathology participants were seen in a metropolitan outpatient clinic affiliated with a large inpatient re- habilitation hospital in Oklahoma. Participants required physician referral prior to evaluation, and consent for treatment and evalu- ation was obtained from each participant. On the basis of their needs, participants were seen by members of the multidisciplinary team, including physical therapy, occupational therapy, psychol- ogy, and recreational therapy, in addition to speech–language pathology. Assessment measures varied, depending on the partic- ipant’s diagnosis, speech–language therapist’s preference, and time constraints. After evaluation, the therapy team established a plan of treatment on the basis of the strengths and weaknesses of each participant and the identified goals. The treatment plan in- cluded short- and long-term goals, as well as frequency and dura- tion of treatment. Daily response recordings were made, and monthly progress and recertification reports were submitted to the physician for continued therapy. The treatment plan was modified to challenge each participant and to facilitate achievement of the treatment goals. The therapeutic approach varied depending on the therapist’s theoretical orientation. Typical approaches included functional, process-specific, and categorical reorganization. Par- ticipants were discharged from therapy if, in the therapist’s judg- ment, the participant’s treatment goals were obtained or maximum benefit had been reached or on self-discharge. As a standard, proficiency on tasks at a minimum of 80% accuracy was estab- lished as a criterion for meeting a treatment goal.

The TELE group included individuals who were referred from a variety of sources, including allied health professionals, physi- cians, state vocational rehabilitation counselors, and neuropsy- chologists. Neither a physician’s order nor an initial face-to-face meeting with the teletherapist was required, although generally such contact occurred. A comprehensive evaluation of the partic- ipant’s neuropsychological functioning was completed before im- plementation of the program. The computer system was installed in the participant’s home, and then he or she was provided with a tutorial of the program. The remaining interventions were com- pleted using a client–server computerized interface system. The teletherapy system included a number of individual exercises, ranging from simple attention and executive tasks to complex visuospatial memory tasks as well as complex problem-solving and decision-making exercises. Participants were encouraged to perform a variety of computer exercises at least once daily and preferably multiple times per day. The participant’s data were then saved to the server following each session. The teletherapist down- loaded the data weekly to monitor the participant’s performance and, if necessary, to modify each participant’s program. Although criterion levels of proficiency exist for each task (e.g., 80% accu- racy), the teletherapist exercised discretion and clinical judgment in deviating from established criterion performance. Participants remained on the computer-based system until they achieved treat- ment goals (e.g., criterion performance) or the teletherapy program was terminated because of lack of sufficient progress, which was determined by the therapist.

Results

Descriptive

There were no group differences in age, gender, years of edu- cation, or hand dominance ( p � .05). In the subsample of partic- ipants completing the WASI and WMS–R, there were no differ- ences between groups in WASI Full-4 or WMS–R Verbal

Table 2 Operational Definitions of Dependent Variables

Variable Definition

Independent living The participant not requiring in-home care. Independent driving The participant passing a driving course or being able to pass the driving

examination administered by the Department of Public Safety for the State of Oklahoma.

Return to work or schoola The participant engaging in 31 or more hours of either paid or volunteer work or school class time.

Hours of therapyb The total number of hours that a participant engaged in either teletherapy or face-to-face therapy. The hours of face-to-face rehabilitation was determined from the number of 15-min billed units aggregated for each participant. The number of hours of teletherapy was estimated on the basis of participant’s self-report.

Cost of treatment divided by hours of therapy

The total cost of treatment was based on dollars for each individual participant divided by the hours of therapy. The variable “cost of treatment” included only actual billed costs of therapy for each group.

Note. Each variable, excluding hours of therapy, was a dichotomous variable. Data represent services from 2001 to 2002. a Combinations of work and school were scored as a successful return if the total time in class and working was greater than 30 hours per week. b Although the computer system recorded the number of times a participant logged onto the computer network, the system did not record the number of minutes a participant was actually running a program or the duration the participant was logged onto the network.

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Memory, Visual Memory, General Memory, Delayed Memory, and Attention/Concentration index scores ( p � .05). There were no participants in the TELE group or the FTF group who were working or attending school, living independently, or driving at the start of the study. The cost of therapy variable was not normally distributed (both groups were leptokurtic and positively skewed), and the log10 of this variable was used for statistical comparisons. Significantly more time had elapsed between the injury and the initiation of rehabilitation (months since injury) for participants in the TELE group compared with the FTF group, F(1, 37) � 4.70, p � .037. In addition, participants in the TELE group spent significantly longer time in therapy, F(1, 37) � 9.70, p � .004, and completed more self-reported hours engaged in teletherapy, F(1, 37) � 18.82, p � .001, than the FTF group. Self-reported hours of therapy ranged from 10 to 243 hours for the TELE group and 6 to 114 hours for the FTF group.

Inferential

There were no significant differences between groups in the proportion of participants living independently, driving, or return- ing to school or work at the conclusion of treatment (see Table 3). However, within-groups analysis of change from baseline to end of treatment revealed that the proportion of participants living inde- pendently, driving, and working significantly improved for both groups ( p � .01). Because of the significant differences between groups in time since injury, this variable was used as a covariate in an analysis of covariance to assess cost differences. The homoge- neity of slopes assumption was not violated. The mean total cost of the TELE group (M � $3,672.00, minimum � $960.00, maxi- mum � $22,620.00) and the FTF group (M � $2,610.48, mini- mum � $629.50, maximum � $7,277.50) did not significantly differ, F(1, 37) � 1.502, p � .228. However, the average cost of therapy per hour significantly differed between groups, F(1, 37) � 10.495, p � .003, with the average cost per hour for the FTF group exceeding the average cost for the TELE group ($103.74 vs. $58.85).

Discussion

The majority of participants receiving either teletherapy or face- to-face rehabilitation services improved on the three primary out- come measures. After an average of 24 weeks of teletherapy, 58% of participants in the TELE group were working or attending

school 31 or more hours per week, 53% were driving indepen- dently, and 71% were living independently. This compares with 72% of the participants in the FTF therapy group who were working or attending school full time, 53% driving independently, and 80% who were living independently. The functional outcome between groups did not significantly differ, and the TELE group participation could minimize several common obstacles or barriers that can interfere with the delivery of rehabilitation services. A particular advantage of the computer rehabilitation system used was that the program permitted participants to engage in the treatment program at their convenience (e.g., unlimited flexibility to access the treatment program). Moreover, the in-home telether- apy program eliminated the need for transportation to and from an office and provided access to therapy more frequently than would likely have been possible for face-to-face rehabilitation. Although the present data suggest that teletherapy yielded similar functional outcomes, the utility of the computer-based rehabilitation program was realized only after longer treatment duration. These data suggest that teletherapy can offer participants who are willing to receive computer-based rehabilitation services an alternative to face-to-face therapy with the potential of increasing cost effective- ness.

Although recent studies have suggested that teletherapy may offer similar outcomes with decreased cost (Brunicardi, 1998; Day & Schneider, 2002; Sandberg & Chodroff, 1998; Schopp et al., 2000; Ziegler, 1995), the cost savings in this study were realized only when evaluated as a function of treatment duration (i.e., unit cost over time). Indeed, the average total cost of treatment per participant in the TELE group was more than the FTF group ($3,672.00 compared with $2,610.00). Although the average total cost of treatment did not significantly differ between groups, a $1,000 difference may be substantial to participants. One factor that increased the average cost of the TELE group was one individual who requested to use the teletherapy computer system for 21 months (total cost � $22,620.00). If this one individual is removed from the analyses, the mean cost of the FTF group decreased to $2,619.33 (SD � $1,220.87, minimum � $960.00, maximum � $4,959.40), which is nearly equivalent to the average for the FTF group (M � $2,610.48, SD � $1,780.90). The subject was retained in the analyses, as the basis for exclusion would be a dependent variable, biasing the results. Finally, it should be noted that the costs of the current study did not include additional costs that may be incurred as part of face-to-face therapy (e.g., travel time, gasoline, etc.), which may be particularly limiting for indi- viduals living in rural areas. These data suggest that teletherapy can provide quality health care relatively inexpensively; however, start-up costs were expensive, and cost savings were realized only with long-term use. The differences in cost and functional outcome as a function of treatment duration highlight the methodological and pragmatic difficulties of cost and outcome-based research and are likely to change as teletherapy becomes increasingly efficient as computer technology develops (Mair, Haycox, & Williams, 2000; Whitten, Kinglsey, & Grigsby, 2000; Whitten et al., 2002; Wootton, 2001).

Several drawbacks to teletherapy computer rehabilitation pro- grams should be identified. Participants with decreased motivation (i.e., abulia) may engage in therapy less frequently, and partici- pants with motor or visual impairment will have greater difficulty operating the computer system independently. In addition, attend-

Table 3 Frequencies of Outcomes by Therapy Group

Outcome

TELE (n � 19)

FTF (n � 20)

pYes No Yes No

Return to independent living 12 5 16 4 .512 Return to independent driving 10 9 9 8 .985 Return to work or school 11 8 13 5 .368

Note. TELE � participant group receiving computer-based teletherapy services; FTF � participant group receiving face-to-face speech–language therapy services. Number of participants may not add up to the full number because of missing data.

173COMPUTER-BASED TELETHERAPY

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ing outpatient therapy may increase participants’ social activity level and decrease isolation.

The longer duration of treatment found for the TELE group raises interesting questions. Because participant outcomes did not differ, one may ask whether the computer-based rehabilitation intervention was less effective per unit of therapy when compared with the face-to-face therapy. These data cannot address this question. Future research could further evaluate the “dose re- sponse” of teletherapy as compared with face-to-face interven- tions. Similarly, research is needed to explore the cost as a function of frequency and engagement, in which each participant receiving the teletherapy program is matched in terms of the type, severity, and location of brain injury, as well as the participants’ premorbid and initial postmorbid levels of neuropsychological functioning to an individual receiving face-to-face services.

This retrospective analysis represents a preliminary attempt to compare a computer-based teletherapy program with face-to-face speech–language cognitive rehabilitation therapy. The generaliz- ability of this study is limited by several factors. The sample size was small, and the participants were not randomly assigned to groups. Treatment fidelity was maintained by close adherence to standard of care for both face-to-face speech–language therapy as well as the computer-based teletherapy program. Treatment was limited to the face-to-face and teletherapy programs, and no par- ticipant received other speech, vocational, or physical therapy during the study. Routine medical care was maintained during the study; however, we did not think that routine care would mean- ingfully affect outcomes on the dependent variables. Family in- volvement in providing cues to initiate treatment was minimized, but some cueing doubtless occurred. Random assignment of par- ticipants was not possible in this study, as random assignment could have adversely affected participants’ involvement in medi- cally necessary treatment. The selection of the treatment program was independent of participants’ severity of injury, time since injury, current neuropsychological functioning, or level of inde- pendence.

Additional limitations to the study should also be noted. The number of hours of computer rehabilitation was determined by each participant’s self-report. As it turned out, a benefit of the computer system—limitless access—also proved to be a weakness because the computer did not record the minutes of teletherapy each participant completed and only the number of times the participant logged onto the system. The length of time since injury was greater for TELE group participants compared with the FTF therapy group, which potentially confounded the effects of natural recovery with treatment type, as some recovery of function has been shown to occur up to 10 years postinjury (e.g., Hammond et al., 2001; Olver, Ponsford, & Curran, 1996; Rappaport, Herrero- Backe, Rappaport, & Winterfield, 1989; Sbordone, Liter, & Pettler-Jennings, 1995). However, all participants were a minimum 1 year from the date of injury, limiting the confound of acute recovery from TBI in accounting for the observed improvement in clinical outcome measures (e.g., Hall, Cope, & Rappaport, 1985). Furthermore, there were no significant differences in measures of IQ, memory, and attention between the subsample of TELE par- ticipants and FTF participants for whom these measures were available, suggesting general equality in neuropsychological func- tioning between groups at the beginning of study. Finally, it is likely that the outcome measures were not sensitive to the subtle

improvements that may have occurred in the participant’s neuro- psychological functioning or other potential treatment effects, such as self-image, executive functioning, or complexity of work role. Similarly, some clinical outcome variables, such as communica- tion skills, ability to manage finances, and time management skills, were not assessed in the study.

In spite of this study’s limitations, these data suggest that computer-based teletherapy provided a viable option for partici- pants with acquired brain injury. We caution, however, this study should not be construed to suggest that teletherapy is preferable to face-to-face rehabilitation services. The functional outcomes of the TELE and FTF groups were similar, and the cost of the computer- based teletherapy system was less expensive compared with face- to-face services only when costs were evaluated as a function of cost per hour of therapy. These data offer additional support for the efficacy of computer-based teletherapy programs for participants who choose to receive rehabilitation services in this manner. Future designs should include more sensitive measures of neuro- psychological functioning, assess participant satisfaction, and at- tempt to further detail the direct and indirect costs of service delivery. The concurrent application of teletherapy and face-to- face therapy services may also be explored.

References

Brown, R., Pain, K., Berwald, C., Hirschi, P., Delehanty, R., & Miller, H. (1999). Distance education and caregiver support groups: Comparison of traditional and telephone groups. Journal of Head Trauma Rehabilita- tion, 14, 257–268.

Brunicardi, B. O. (1998). Financial analysis of savings from telemedicine in Ohio’s prison system. Telemedicine Journal, 4, 49 –54.

Burns, R. B., Crislip, D., Daviou, P., Temkin, A., Vesmarovich, S., Anshutz, J., et al. (1998). Using telerehabilitation to support assistive technology. Assistive Technology, 10, 126 –133.

Carney, N., Chesnut, R. M., Maynard, H., Mann, N. C., Patterson, P., & Helfand, M. (1999). Effect of cognitive rehabilitation on outcomes for persons with traumatic brain injury: A systematic review. Journal of Head Trauma Rehabilitation, 14, 277–307.

Chen, S. H., Thomas, J. D., Glueckauf, R. L., & Bracy, O. L. (1997). The effectiveness of computer-assisted cognitive rehabilitation for persons with traumatic brain injury. Brain Injury, 11, 197–209.

Cicerone, K. D. (1999). Commentary: The validity of cognitive rehabili- tation. Journal of Head Trauma Rehabilitation, 14, 316 –321.

Cicerone, K. D., Dahlberg, C., Kalmar, K., Langenbahn, D. M., Malec, J. F., Bergquist, T. F., et al. (2000). Evidence-based cognitive rehabili- tation: Recommendations for clinical practice. Archives of Physical Medicine Rehabilitation, 81, 1596 –1615.

Clark, P. G., Dawson, S. J., Scheideman-Miller, C., & Post, M. L. (2002). TeleRehab: Stroke teletherapy and management using two-way interac- tive video. Neurology Report, 26, 87–93.

Conrad, K. (1998). Making telehealth a viable component of our national health care system. Professional Psychology: Research and Practice, 29, 525–526.

Day, S. X., & Schneider, P. L. (2002). Psychotherapy using distance technology: A comparison of face-to-face, video, and audio treatment. Journal of Counseling Psychology, 49, 499 –503.

Fitzgerald, M., Yee, H., Geobert, D., & Okamoto, G. (1992). Rehabilitation technicians for remote rural communities. World Health Forum, 13, 303–306.

Hailey, D., Roine, R., & Ohinmaa, A. (2002). Systematic review of evidence for the benefits of telemedicine. Journal of Telemedicine and Telecare, 8, 1–30.

174 SCHOENBERG ET AL.

T hi

s do

cu m

en t i

s co

py ri

gh te

d by

th e

A m

er ic

an P

sy ch

ol og

ic al

A ss

oc ia

tio n

or o

ne o

f i ts

a lli

ed p

ub lis

he rs

. T

hi s

ar tic

le is

in te

nd ed

s ol

el y

fo r t

he p

er so

na l u

se o

f t he

in di

vi du

al u

se r a

nd is

n ot

to b

e di

ss em

in at

ed b

ro ad

ly .

Hall, K., Cope, N., & Rappaport, M. (1985). Glasgow Outcome Scale and Disability Rating scale: Comparative usefulness in following recovery in traumatic head injury. Archives of Physical Medicine and Rehabilitation, 66, 35–37.

Hammond, F. M., Grattan, K. D., Sasser, H., Corrigan, J. D., Bushnik, T., & Zafonte, R. D. (2001). Long-term recovery course after traumatic brain injury: A comparison of the functional independence measure and disability rating scale. Journal of Head Trauma Rehabilitation, 16, 318 –329.

Harley, J. P., Allen, C., Braciszewski, T. L., Cicerone, K. D., Dahlberg, C., Evans, S., et al. (1992). Guidelines for cognitive rehabilitation. Neuro- Rehabilitation, 2, 62– 67.

Lacroix, A., Lareng, L., Padeken, D., Nerlich, M., Bracale, M., Ogushi, Y., et al. (2002). International concerted action on collaboration in telemedi- cine: Recommendations of the G-8 Global Healthcare Applications Subproject-4. Telemedicine Journal and e-Health, 8, 149 –157.

Mair, F. S., Haycox, A., & Williams, T. (2000). A review of telemedicine cost-effectiveness studies. Journal of Telemedicine and Telecare, 6(Suppl. 1), 38 – 40.

Mair, F., & Whitten, P. (2000). Systematic review of studies of patient satisfaction with telemedicine. British Medical Journal, 320, 1517– 1520.

Max, W., MacKenzie, E. J., & Rice, D. P. (1991). Head injuries: Costs and consequences. Journal of Head Trauma Rehabilitation, 6, 76 –91.

McGarry, L. J., Thompson, D., Millham, F. H., Cowell, L., Snyder, P. J., Lenderking, W. R., & Weinstein, M. C. (2002). Outcomes and costs of acute treatment of traumatic brain injury. Journal of Trauma: Injury, Infection, and Critical Care, 53, 1152–1159.

National Academy of Neuropsychology. (2002). Position paper: Cognitive rehabilitation. Retrieved January 13, 2003, from http://www.nanonline .org/paio/cogrehab.shtm

Olver, J. H., Ponsford, J. L., & Curran, C. A. (1996). Outcome following traumatic brain injury: A comparison between 2 and 5 years after injury. Brain Injury, 10, 841– 848.

Phipps, E. J., & Allman, R. (1999). Rehabilitation: A luxury? Journal of Head Trauma Rehabilitation, 14, 329 –331.

Popescu, V. G., Burdea, G. C., Bouzit, M., & Hentz, V. R. (2000). A virtual-reality-based telerehabilitation system with force feedback. IEEE Transactions on Information Technology Biomedicine, 4, 45–51.

Prigatano, G. P. (1999). Commentary: Beyond statistics and research design. Journal of Head Trauma Rehabilitation, 14, 308 –311.

Psychological Corporation. (1999). Manual for the Wechsler Abbreviated Scale of Intelligence (WASI). San Antonio, TX: Author.

Rappaport, M., Herrero-Backe, C., Rappaport, M. L., & Winterfield, K. M. (1989). Head injury outcome up to ten years later. Archives of Physical Medicine and Rehabilitation, 70, 885–992.

Ricker, J. H. (1998). Traumatic brain injury rehabilitation: Is it worth the cost? Applied Neuropsychology, 5, 184 –193.

Riva, G., & Gamberini, L. (2000). Virtual reality as telemedicine tool: Technology, ergonomics and actual applications. Technology Health Care, 8, 113–127.

Roine, R., Ohinmaa, A., & Hailey, D. (2001). Assessing telemedicine: A systematic review of the literature. Canadian Medical Association Jour- nal, 165, 765–771.

Salvatore, T. (2002). A telehealthcare primer for managers. Home Health- care Nurse, 20, 127–130.

Sandberg, L., & Chodroff, P. (1998). TENN rates an 11: Northern Cali- fornia telemedicine project saves $500,000. Health Management Tech- nology, 19, 29 –30.

Sbordone, R. J., Liter, J. C., & Pettler-Jennings, P. (1995). Recovery of function following severe traumatic brain injury: A retrospective 10-year follow-up. Brain Injury, 9, 285–299.

Schopp, L., Johnstone, B., & Merrell, D. (2000). Telehealth and neuropsy- chological assessment: New opportunities for psychologists. Profes- sional Psychology: Research and Practice, 31, 179 –183.

Sjogren, L. H., Tornqvist, H., Schwieler, A., & Karlsson, L. (2001). The potential of telemedicine: Barriers, incentives and possibilities in the implementation phase. Journal of Telemedicine and Telecare, 7(Suppl. 1), 12–13.

Sosin, D. M., Sniezek, J. E., & Thurman, D. J. (1996). Incidence of mild and moderate brain injury in the United States, 1991. Brain Injury, 10, 47–54.

Wechsler, D. (1981). Wechsler Adult Intelligence Scale—Revised. San Antonio, TX: Psychological Corporation.

Wechsler, D. (1987). Wechsler Memory Scale—Revised. San Antonio, TX: Psychological Corporation.

Whitten, P., Kingsley, C., & Grigsby, J. (2000). Results of a meta-analysis of cost-benefit research: Is this a question worth asking? Journal of Telemedicine and Telecare, 6(Suppl. 1), 4 – 6.

Whitten, P. S., Mair, F. S., Haycox, A., May, C. R., Williams, T. L., & Hellmich, S. (2002). Systematic review of cost effectiveness studies of telemedicine interventions. British Medical Journal, 324, 1434 –1437.

Winters, J. M. (2002). Telerehabilitation research: Emerging opportunities. Annual Review of Biomedical Engineering, 4, 287–320.

Woods, K., Kutlar, A., Grigsby, R. K., Adams, L., & Stachura, M. E. (1998). Primary-care delivery for sickle cell patients in rural Georgia using telemedicine. Telemedicine Journal, 4, 353–361.

Wootton, R. (2001). Recent advances: Telemedicine. British Medical Jour- nal, 323, 557–560.

Ziegler, J. (1995). Telemedicine starts to pay off. Business Health, 13, 47–50.

Received May 17, 2006 Revision received January 25, 2007

Accepted March 12, 2007 �

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