This study describes the features and utility of a novel augmented reality based telemedicine system with haptics that allows the sense of touch and direct physical examination during a synchronous immersive telemedicine consultation and physical examination. The system employs novel engineering features: (a) a new force enhancement algorithm to improve force rendering and overcoming the “just-noticeable-difference” limitation; (b) an improved force compensation method to reduce the delay in force rendering; (c) use of the “haptic interface point” to reduce disparity between the visual and haptic data; and (d) implementation of efficient algorithms to process, compress, decompress, transmit and render 3-D tele-immersion data. A qualitative pilot study (n=20) evaluated the usability of the system. Users rated the system on a 26-question survey using a seven-point Likert scale, with percent agreement calculated from the total users who agreed with a given statement. Survey questions fell into three main categories: (1) ease and simplicity of use, (2) quality of experience, and (3) comparison to in-person evaluation. Average percent agreements between the telemedicine and in-person evaluation were highest for ease and simplicity of use (86%) and quality of experience (85%), followed by comparison to in-person evaluation (58%). Eighty-nine percent (89%) of respondents expressed satisfaction with the overall quality of experience. Results suggest that the system was effective at conveying audio-visual and touch data in real-time across 20.3 miles, and warrants further development.

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BackgroundEpidural steroid injections (ESIs) may be beneficial for lumbar spinal stenosis (LSS) symptoms. Past studies found interferon‐gamma, fibronectin‐aggrecan complex, and electromyography (EMG) to predict patients' response to ESIs for other spinal pathologies, but no similar studies have been done for LSS.ObjectiveTo explore the ability of biomarkers and EMG to help predict outcome after ESI in LSS.DesignProspective observational cohort.SettingThe physical medicine & rehabilitation spine clinic at a tertiary care center.ParticipantsEleven patients with LSS were recruited from the spine clinic at a Veterans Affairs Medical Center.InterventionsParticipants underwent one interlaminar ESI. Before ESI, the following data were collected: pain intensity on visual analog scale (VAS), disability via the Pain Disability Questionnaire (PDQ) and LSS symptoms via the Swiss Spinal Stenosis Questionnaire (SSSQ), serum high‐sensitivity C‐reactive protein level, standard diagnostic EMG, assay of epidural lavasate (epidural saline lavage performed immediately prior to ESI) and serum cytokine biomarkers indicative of inflammation.Outcome MeasuresLeg pain intensity (VAS), disability (PDQ), LSS symptoms (SSSQ) and satisfaction (SSSQ satisfaction subscale) were assessed at 1 and 2 months following ESI. Pearson correlational coefficients were calculated between independent variables and outcome measures.ResultsSerum monocyte chemoattractant protein‐1 (MCP‐1) level positively correlated with improvement on 2‐month satisfaction. Abnormal EMG finding of radiculopathy positively correlated with improvement in PDQ score at 1 month. Epidural cytokine levels were not detectable in most samples, except for scattered marginally elevated levels in a few cytokines such as MCP‐1, RANTES (Regulated on Activation, Normal T Cell Expressed and Secreted) and interleukin‐1b.ConclusionsThis exploratory pilot study revealed that some biomarkers and EMG findings indicative of inflammation and nerve root injury may be predictive of improvement following ESI in patients with LSS. The results of this study will be used to inform a fully powered study to further evaluate these relationships in LSS patients.

Introduction: Utilization of telemedicine for health care delivery increased rapidly during the coronavirus disease 2019 (COVID-19) pandemic. However, physical examination during telehealth visits remains limited. A novel telerehabilitation system-The Augmented Reality-based Telerehabilitation System with Haptics (ARTESH)-shows promise for performing synchronous, remote musculoskeletal examination.Objective: To assess the potential of ARTESH in remotely examining upper extremity passive range of motion (PROM) and maximum isometric strength (MIS). Design: In this cross-sectional pilot study, we compared the in-person (reference standard) and remote evaluations (ARTESH) of participants' upper extremity PROM and MIS in 10 shoulder and arm movements. The evaluators were blinded to each other's results. Setting: Participants underwent in-person evaluations at a Veterans Affairs hospital's outpatient Physical Medicine and Rehabilitation (PM&R) clinic, and underwent remote examination using ARTESH with the evaluator located at a research lab 30 miles away, connected via a high-speed network. Patients: Fifteen participants with upper extremity pain and/or weakness. Interventions: Not applicable. Main Outcome Measures: Inter-rater agreement between in-person and remote evaluations on 10 PROM and MIS movements and presence/absence of pain with movement was calculated.Results: The highest inter-rater agreements were noted in shoulder abduction and protraction PROM (kappa (κ) = 0.44, confidence interval (CI): À0.1 to 1.0), and in elbow flexion, shoulder abduction, and shoulder protraction MIS (κ = 0.63, CI: 0 to 1.0). Conclusions: This pilot study suggests that synchronous tele-physical examination using the ARTESH system with augmented reality and haptics has the potential to provide enhanced value to existing telemedicine platforms. With the additional technological and procedural improvements and with an adequately powered study, the accuracy of ARTESH-enabled remote tele-physical examinations can be better evaluated.

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