Australian Occupational Therapy Journal (2008) 55, 239–248
Research Article
Blackwell Publishing Asia
Occupational therapy services for adult neurological
clients in Queensland and therapists’ use of telehealth to
provide services
Tammy Hoffmann and Nicola Cantoni
Division of Occupational Therapy, School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane,
Queensland, Australia
Background/Aim: Occupational therapy is an important
component of neurological rehabilitation. Clients in rural
areas have fewer opportunities to receive rehabilitation than
those in metropolitan areas. Telehealth is a potential method
of closing these gaps in service delivery, although research
into telehealth applications for neurological rehabilitation is
extremely limited. To assist in the development of appropriate
telehealth applications, this study aimed to identify the nature
of occupational therapy services for neurological rehabilitation
in areas of Queensland other than the capital city of Brisbane,
the barriers to service delivery, and the current uses of
various information and communication technologies among
occupational therapists.
Methods: A self-administered questionnaire was sent to
occupational therapists working in adult neurological
rehabilitation in all areas of Queensland other than the
capital city of Brisbane. Contact details were obtained from
OT AUSTRALIA Queensland.
Results: Responses were received from 39 eligible par-
ticipants. The client’s home was the most frequent setting
in which participants saw clients. Home visits and modifica-
tions, equipment prescription, client/family education, and
activities of daily living assessment and retraining were the
most common interventions provided by participants.
Frequently identified barriers to service provision included
travelling distance to clients, large workloads and limited
resources. Telephone, email, fax, the Internet and videocon-
Tammy Hoffmann PhD, BOccThy (Hons); Lecturer. Nicola
Cantoni BOccThy (Honours); was honours student at time
of data collection for this study.
Correspondence: Tammy Hoffmann, Division of Occupational
Therapy, School of Health and Rehabilitation Sciences, The
University of Queensland, Brisbane, Qld 4072, Australia.
Email: t.hoffmann@uq.edu.au
Accepted for publication 28 March 2007.
© 2007 The Authors
Journal compilation © 2007 Australian Association of
Occupational Therapists
doi: 10.1111/j.1440-1630.2007.00693.
ferencing were available in most workplaces. Few participants
used the Internet or videoconferencing for purposes other
than continuing professional development.
Conclusions: Home-based assessment and intervention
appear to be frequent components of occupational therapy
practice among therapists working in neurological rehabilita-
tion. The use of telehealth to provide direct home-based client
services is currently limited, but should be explored as a
possible solution to overcome some of the identified barriers
to occupational therapy service provision for clients with
neurological conditions in rural and remote areas.
KEY WORDS neurology, rehabilitation, rural, telehealth,
technology.
Introduction
People who live in rural and remote areas of Australia
have poorer health status than those who live in met-
ropolitan areas (Australian Institute of Health and Wel-
fare (AIHW), 1998) and many Australians are significantly
disadvantaged when it comes to accessing health services.
Factors such as the urbanisation of health services, long
distances needed to travel to services, lack of transporta-
tion, and difficulties in recruiting and retaining health
professionals in rural and remote areas contribute to
health access issues (Bourke, 2001; FitzGerald, Pearson &
McCutcheon, 2001; Mills & Millsteed, 2002). Difficulties
recruiting and retaining occupational therapists in rural
and remote areas and the resultant shortage of therapists
are well documented (Lannin & Longland, 2003; Mill-
steed, 2000; Mills & Millsteed). In Queensland, 48% of the
population live in rural and remote regions, but only
approximately 34% of the allied health workforce reside
there (Services for Australian Rural and Remote Allied
Health (SARRAH), 2003).
Telehealth has been suggested as a means of improving
rural and remote communities’ access to health care
(Demiris, Shigaki & Schopp, 2005) and a way for occupa-
tional therapists to provide services across large geo-
graphical distances (Boshoff, 2003). It has also been
240
suggested that the appropriate use of information tech-
nology for providing client services may also facilitate
the retention of therapists in rural areas (Bent, 1999). Tel-
ehealth has been defined as providing health-care services
at a distance (Darkins & Carey, 2000) and is one aspect of
information and communication technologies (ICT).
There has been very limited exploration of occupational
therapists’ use of ICT in the literature. To date, occupa-
tional therapists’ use of ICT has been primarily for contin-
uing professional development and/or clinical support
purposes (Taylor & Lee, 2005). Telehealth has predomi-
nantly been used as a support tool for rural therapists to
decrease their sense of isolation and increase the profes-
sional support available to them (Jin, Ishikawa, Sengoku
& Ohyanagi, 2000). No studies have explored occupational
therapists’ use of telehealth to provide client services.
In a study that examined occupational therapists’ per-
ception of usage of ICT and the association between ICT
availability and the recruitment and retention of rural
therapists in Western Australia (Taylor & Lee, 2005), 51%
of rural therapists reported that they had used videocon-
ferencing to serve clients, but it is not clear what to mean
by ‘serve’ clients and whether this refers to indirect or
direct client services. When telehealth is used for remote
consultations, benefits for health professionals can include
less travel time and consequently more time for other
duties, and the reduced need to travel in poor weather
(Aas, 2002). As rural and remote clients typically have to
travel further for their health care than metropolitan
clients and incur inconveniences and higher travel and
opportunity costs (such as lost time at work) as a result
(Grimmer & Bowman, 1998), remote consultations may be
valuable in reducing these costs and inconveniences.
The focus of this study was narrowed to occupational
therapists who work with adult clients with neurological
conditions. As clients with neurological conditions require
considerable health system resources (Neurological
Alliance, 2003) and the chronic and often progressive
nature of some neurological conditions means that there
is a need for occupational therapy services to continue
postdischarge and for extended periods of time (Eriksson,
Tham & Borg, 2006; Gilbertson, Langhorne, Walker, Allen
& Murray, 2000), there might be scope for therapists who
work with these clients to use telehealth as a tool to assist
in providing services.
Telehealth systems have been successfully trialed in
many medical fields including cardiology, dermatology,
psychiatry and oncology (Lemaire, Boudrias & Greene,
2001). In the field of neurological rehabilitation, the
majority of studies have examined the use of telehealth
systems for the medical management of acute stroke in
rural areas (Hess et al., 2005, 2006; LaMonte et al., 2003).
No published studies have explored the use of telehealth
applications to provide occupational therapy-specific
interventions to clients with neurological conditions.
Although it may be feasible to design a telehealth sys-
tem that enables the provision of occupational therapy to
Journal compilation © 2007 Australian Association of Occupational Therapists
T. HOFFMANN AND N. CANTONI
clients with neurological conditions in rural and remote
areas, for the system to meet the needs of therapists and
clients and to become successfully integrated into prac-
tice, information needs to be known about the current
practices and needs of occupational therapists in rural
and remote areas. There are no data available regarding
the nature and availability of occupational therapy serv-
ices for clients with a neurological condition in Queens-
land or therapists’ current use of and willingness to use
telehealth to provide services.
The purposes of this study were to determine what
occupational therapy services are available to clients
with a neurological condition in areas of Queensland
other than Brisbane; to identify, from the perspective of
occupational therapists, the barriers to service delivery in
these areas; and to identify, according to occupational
therapists, the current applications of and barriers to using
ICT for service delivery.
Methods
Participants
Participants were occupational therapists deemed eligi-
ble if they met the following inclusion criteria: (i) cur-
rently practising as a registered occupational therapist in
Queensland, (ii) currently providing therapy services to
adult clients with a neurological condition, and (iii) cur-
rently working in any area of Queensland other than the
capital city of Brisbane.
Instrumentation
As no suitable questionnaire existed, a self-administered
questionnaire was developed for this study. Prior to the
commencement of data collection, the questionnaire was
piloted with five occupational therapists who work with
adult clients with a neurological condition in rural areas.
Minor adjustments were made to the content and format
of some of the questions following feedback from the
pilot participants.
The final questionnaire contained four sections: (i)
participants’ demographic details (age, gender, postcode);
(ii) caseload characteristics; (iii) Rehabilitation services
provided; and (iv) use of ICT in practice.
In section ii, participants were asked to estimate the
percentage of their working week spent in direct contact
with clients, to provide information about the settings in
which they see clients (inpatient, outpatient, hostel or
nursing home, home, community centre, private practice,
or other) and an estimated breakdown of their neurological
caseload by diagnosis (stroke, brain injury, Parkinson’s
disease, or other). Participants were also asked to esti-
mate, on average, for their last 10 clients with a neuro-
logical condition, how often they had contact with these
clients (daily, few times per week, weekly, fortnightly,
monthly, or other), and the time and distance both the
therapist and/or the client spent travelling to and from
appointments. Finally, participants were asked to indicate
© 2007 The Authors
TELEHEALTH AND OCCUPATIONAL THERAPY
whether environmental factors or the distance needed to
travel to meet clients limits the number of consultations
that are provided. If they answered ‘yes’, participants
were asked to provide examples of these environmental
limitations and estimate how often the provision of ther-
apy sessions was affected as a result (never, rarely, some-
times, often, or nearly always).
For section iii, participants were requested to select,
from a provided list, which rehabilitation services they
provide to clients with a neurological condition. Addi-
tionally, participants were invited to list any interven-
tions they are unable to offer clients and reasons for
this. They were also asked to: estimate the percentage of
their clientswho receive initial treatment in a non-local
facility, indicate if therapists in larger centres asked them
to provide interventions to clients once they returned to
the local area, and list the typical interventions they pro-
vide to these clients.
In section iv, participants were asked to indicate
the availability and various uses of ICT (telephone, fax,
email, Internet, videoconferencing, other) at their work-
place, and the availability (never, usually unavailable,
sometimes, usually available, always) of various tele-
phone and Internet services in their community. Using
Likert scales (1 = completely disagree and 5 = com-
pletely agree), participants were asked to rate their satis-
faction, willingness, and confidence in using ICT for
client service delivery. With an open-ended question,
participants were invited to explain what they perceive
to be limitations of using ICT for client service delivery.
Procedure
Ethical approval for this study was obtained from one of
the University of Queensland’s ethics committees. Con-
sent to contact member occupational therapists was also
obtained from OT AUSTRALIA Queensland. Data for
this study were collected between April and August
2006. Initially, a bulk email was sent via OT AUS-
TRALIA Queensland to all members in areas of Queens-
land other than Brisbane who had an email address
listed (n = 315), inviting them to participate, and encour-
aging them to forward the email to other colleagues who
may be eligible to participate. The participant informa-
tion sheet and questionnaire were attached to the
email. Consent to participate was implied if partici-
pants returned a completed questionnaire.
Two weeks after the initial email, a reminder email
was sent to this same group of therapists. Because of a
low response rate following the initial and reminder
emails, two additional strategies were used in an attempt
to enhance the response rate and ensure that as many eli-
gible occupational therapists as possible received an
invitation to complete the questionnaire.
1 As a personalised email/letter may be more effective in
obtaining a response than a bulk email (Scott &
Edwards, 2006), contact details of therapists who
work in areas of Queensland other than Brisbane
were obtained from OT AUSTRALIA Queensland’s
© 2007 The Authors
Journal compilation © 2007 Australian Association of Occupational Therapists
241
Who’s Working Where directory, which was accessed
via the association’s website. Ninety occupational
therapists were sent an individualised email, inviting
them to participate. Therapists whose email address
was not provided in the directory (n = 50) were
posted a copy of the participant information sheet
and questionnaire.
2 Occupational therapists registered to practise in
Queensland are not required to become members of
OT AUSTRALIA Queensland. In 2005, 68% of regis-
tered occupational therapists in Queensland were
members of OT AUSTRALIA Queensland (OT AUS-
TRALIA Queensland, 2005). In an attempt to contact
non-member occupational therapists, a copy of the
participant information sheet and questionnaire
was posted to The Director of the Allied Health/
Occupational Therapy Department of all non-Brisbane
hospitals and relevant health facilities in Queensland
(n = 153).
Data analysis
Quantitative data were analysed descriptively using
the Statistical Package for the Social Sciences (SPSS) for
Windows, version 11 (SPSS Inc., Chicago, IL, USA).
Responses to open-ended questions were analysed
according to common themes. Postcodes were used to
determine the population of the towns where partici-
pants worked. The Rural, Remote and Metropolitan
Areas (RRMA) classification (AIHW, 2004) was then
used to classify the geographical location of participants.
Results
A total of 608 questionnaires were distributed as part of
this study. Thirty-nine questionnaires were returned and
included for data analysis. It was not possible to calculate
a response rate as some therapists may have received the
questionnaire more than once and of the therapists who
were invited to participate, it is not known what propor-
tion were currently working with adult clients with neu-
rological conditions and therefore eligible to complete
the questionnaire.
Demographic data
The majority (61.5%) of participants were aged less than
30 years and 92.3% were female. According to the RRMA
classification, five (12.9%) of participants were working
in a remote area, 24 (61.5%) in a rural area, and 10 (25.6%)
in a metropolitan centre (with a population ≥ 100 000).
Caseload characteristics
Stroke was the neurological condition most frequently
seen by participants, with 38.5% reporting that clients with
stroke comprised 40% or more of their caseload. The next
most frequently seen neurological conditions were cli-
ents with brain injury (seen by 9.1% of participants) and
clients with Parkinson’s disease (seen by 5.4% of partici-
pants). Clients with multiple sclerosis, motor neurone
242 T. HOFFMANN AND N. CANTONI

disease, or dementia were other neurological conditions TABLE 1: Rehabilitation services provided by participants
that participants reported seeing. (n = 39) to clients with a neurological condition
When asked to estimate the percentage of the working
week spent in direct client contact, the most frequently Rehabilitation service n (%)
selected category was 60 –79%, chosen by 46.1% of partic-
ipants. The client’s home was the most frequently chosen Home visits 39 (100.0)
setting in which participants saw clients, followed by Equipment prescription 39 (100.0)
rehabilitation unit, inpatient ward, outpatient depart- Home modifications 38 (97.4)
ment, community centre, private practice, client’s work- Client education 37 (94.9)
place, and hostel or nursing home. For the question, ‘Of
Basic ADL assessment 36 (92.3)
your last 10 clients with a neurological condition, how
Basic ADL retraining 33 (84.6)
often did you have contact with the client?’, the most
Family education 32 (82.1)
frequently selected category was weekly, chosen by
Cognitive assessment 32 (82.1)
28.2% of participants, followed by a few times per week
Cognitive retraining 30 (76.9)
(23.1%), daily (17.9%), other (e.g. one-off assessment,
Upper limb assessment 29 (74.4)
15.4%), fortnightly (7.7%), and monthly (7.7%).
When participants were asked to estimate the average Upper limb rehabilitation 28 (71.8)
time and distance travelled (return) by themselves and Perceptual assessment 27 (69.2)
their clients with neurological conditions to and from Social/leisure roles 27 (69.2)
therapy appointments, over one-third (14, 35.8%) indi- Instrumental ADL assessment 26 (66.9)
cated that they had to travel for greater than 30 min to Perceptual retraining 25 (64.1)
see clients, and 28.2% indicated that they had to travel Sensory assessment 23 (59.0)
more than 50 km. In terms of client travel, 56.4% of par- Sensory retraining 21 (53.8)
ticipants estimated that their clients had to travel to Instrumental ADL retraining 21 (53.8)
attend appointments with them, and 12.8% of partici- Return to work assistance 17 (43.6)
pants estimated the travelling time for clients to be more Other (e.g. splinting, driving assessment) 6 (15.4)
than 30 min.
Seventeen participants (43.6%) reported the existence of ADL, activities of daily living.
environmental factors that limit client appointments
occurring, with the majority (76.9%) of these participants
indicating that this occurs ‘sometimes’ or ‘often’. The ventions per se but related to wanting to alter how often
most frequently provided examples of environmental and where intervention was provided, namely more
limitations were: distance to travel for client or therapist, intensive therapy, home-based/community therapy,
unsuitable road conditions (e.g. poor roads, cattle on and home visits to a larger proportion of their clients. The
road, flooded roads), and ‘other’ (e.g. poor weather, lack main reasons that were given for being unable to offer
of public transport). Twenty-six participants (66.7%) these interventions included: lack of time, large work-
reported that the distance required to travel to meet cli- load, long distances to travel to see clients, and lack of
ents limits the number of therapy sessions that are pro- appropriate resources (such as staff and funding). One
vided. Some participants reported that the long distance additional intervention that some participants (28%)
between them and particular clients, combined with a indicated that they would like to be able to provide was
lack of public transport, meant that these clients could driving assessment/retraining.
only be seen when the participants were on outreach, Participants were asked to estimate the percentage of
usually once a month. their clients with neurological conditions who receive
initial treatment in a non-local health facility. There was
Rehabilitation services provided wide variation as to the percentage of clients who are
Table 1 lists the interventions that participants typically initially treated in a non-local health facility. Twenty-
provide to clients with a neurological condition. Home nine per cent of participants reported that most (80–
visits and equipment prescription were the only two 100%) of their clients received initial treatment in a non-
interventions provided by all participants. With the local hospital, 26% of participants estimated that this was
exception of return to work services, the remaining the case for 40–79% of their clients, 16% reported this for
interventions were provided by at least half of the 20–39% of their clients, and 29% indicated that this was
participants. the case for less than 20% of their clients. Twenty-nine
Twenty-five (64.1%) participants described interven- (74.4%) participants reported that they were sometimes
tions that they are currently unable to offer clients. Of contacted by therapists in larger centres to provide inter-
these participants, 18 (72%) were working in ‘rural’ or vention/s before or once the client returned home. The
‘remote’ areas as defined by the RRMA classification. The interventions that participants were most frequently asked
three most frequent responses were not additional inter- to provide were home visits/modifications (71.4%), ongoing

© 2007 The Authors

Journal compilation © 2007 Australian Association of Occupational Therapists
TELEHEALTH AND OCCUPATIONAL THERAPY 243

rehabilitation (57.1%), equipment prescription (34.3%),

development
professional
Continuing
further assessment (28.6%), client and family/carer edu-

21 (53.8)
10 (25.6)
23 (59.0)
29 (74.4)
26 (66.7)
cation (20.0%), community access assistance (11.4%),

2 (5.1)
assistance with return-to-work (8.6%), and assistance
with resuming social/leisure roles (5.7%). Thirty-one
(79.5%) participants indicated that the intervention/s
requested by the therapists in larger centres often needed

1 (2.6)
1 (2.6)
1 (2.6)
2 (5.1)
0 (0.0)
3 (7.7)
Other
to be provided before they have met the client. This was
primarily when the requested intervention was home
visits/modifications.

Follow up
of clients

33 (84.6)
4 (10.3)
4 (10.3)
Use of ICT in practice

0 (0.0)
1 (2.6)
0 (0.0)
Table 2 presents data concerning the ICT available in
participants’ workplaces and the various uses of these
technologies. Telephone and email were the only two
technologies that were available for use in the work-

intervention-related
places of all participants. Participants’ most common use
of the technologies was for ‘continuing professional devel-

Organising
opment’, followed by ‘organising intervention-related

17 (43.6)
10 (25.6)
6 (15.4)
services
services’ (e.g. liaising with equipment suppliers and/or

3 (7.7)
3 (7.7)
1 (2.6)
other health professionals), ‘client/carer education’, ‘fol-
low-up of clients’, ‘direct communication with client/

Availability, various uses of information communication technologies in participants’ workplaces (n = 39)

carer’, ‘conducting assessments’, and ‘other’. The two
‘other’ uses of technologies that were provided by partici-

Client/carer
pants were finding resources for clients/carers and

education

24 (61.5)
5 (12.8)
4 (10.3)
5 (12.8)
maintaining contact with clients/carers. The telephone

2 (5.1)
1 (2.6)
was the most widely used type of technology for all rea-
sons. Videoconferencing and the Internet were the least
used technologies, other than for continuing professional
development activities.
assessments
Conducting
The majority of participants (79.5%) rated landline tel-

10 (25.6)
0 (0.0)
0 (0.0)
0 (0.0)
2 (5.1)
1 (2.6)
ephone services as ‘always available’ in their community,
with 15.4% responding with ‘usually available’, and 5.1%
with ‘usually unavailable’. There was variation as to the
availability of mobile telephone services with 56.4% of
participants indicating that they were ‘always or usually
with client or carer

available’, 35.9% indicating ‘sometimes available’, and

communication

7.7% ‘usually unavailable’. Most participants (61.7%)

indicated that dial-up Internet services were ‘always or
19 (48.7)

7 (17.9)

4 (10.3)
2 (5.1)

0 (0.0)

2 (5.1)

usually available’, with 17.6% reporting this service was

Direct

‘usually or always unavailable’. Broadband Internet services

were reported as ‘always or usually available’ by 45.7%
of participants, with 25.7% reporting ‘sometimes available’,
and 28.5% ‘always or usually unavailable’. Over half
Available

39 (100.0)

39 (100.0)
38 (97.4)

34 (87.2)
31 (79.5)
1 (2.6)

(52.4%) of participants reported that satellite Internet

for use
n (%)

services were unavailable in their community.

Participants’ mean score for satisfaction with the ICT
available for client service delivery was 3.6 (SD 0.9, range
1–5). Their mean scores for willingness to use and confi-
Other (e.g. digital camera)

dence in using the technologies for client service delivery

were 3.4 (SD 1.4, range 1–5) and 3.5 (SD 1.3, range 1–5),
Type of technology

Videoconferencing

respectively. Thirty participants (76.9%) responded to

the open-ended question about the perceived limita-
tions associated with using technologies for client service
Telephone
TABLE 2:

delivery. Common themes were: lack of face-to-face and/

Internet
Email

or hands-on contact with clients, necessary equipment

Fax

not available in client’s home or community (particu-

© 2007 The Authors

Journal compilation © 2007 Australian Association of Occupational Therapists
244
larly videoconferencing equipment), lack of technical
support and training in use of the technologies, and con-
cerns about equipment reliability.
Discussion
This study aimed to obtain information regarding the
nature of occupational therapy services for clients with
neurological conditions in areas of Queensland other
than the capital city, therapists’ perceived barriers to
service delivery, and their current use of and perceived
limitations of ICT for service delivery. Stroke was the
neurological condition most frequently seen by partici-
pants. Rijken & Dekker (1998) examined the diagnostic
groups seen by rehabilitation professionals and found
that stroke was the most common chronic disease
category seen by occupational therapists working in
institutional and non-institutional settings. A survey of
Australian occupational therapists (13.6% from Queens-
land) who work in adult physical dysfunction settings
found that there is some similarity between the interven-
tions provided to clients with stroke and those with
other neurological conditions such as brain injury and
Parkinson’s disease (McEneany, McKenna & Summerville,
2002). An implication of this is that a telehealth applica-
tion that is developed to provide occupational therapy
interventions to clients with stroke may also be able to
be used to provide interventions to clients with other
neurological conditions.
The interventions that participants reported most com-
monly providing to clients, such as home visits, home
modifications, equipment prescription, activities of
daily living (ADL) assessment and retraining, cogni-
tive assessment, and client and family/carer education,
were identified as frequently provided interventions in
other studies that have examined the interventions pro-
vided by occupational therapists in adult physical dys-
function settings (Latham et al., 2006; McEneany et al.,
2002). As many of these interventions focus on the cli-
ent’s home and/or their functioning in it, telehealth
applications that enable therapists to provide home-
based therapy, without the therapist having to travel to
the client’s house, would be useful.
This recommendation is further supported by the
finding in this study that the client’s home was the most
frequent setting in which participants saw clients. In
addition to the evidence that supports the effectiveness
of home-based therapy for people with traumatic brain
injury (Powell, Heslin & Greenwood, 2002) and stroke
(Corr & Bayer, 1995; Gilbertson & Langhorne, 2000;
Walker, Gladman, Lincoln, Siemonsma & Whiteley, 1999),
the chronic and complex nature of neurological condi-
tions often means that it is unlikely that all of clients’
therapy needs and goals will be met while in hospital,
and therapy typically needs to continue once the client
has returned home (Ko Ko, 1999; Rice-Oxley & Turner-
Stokes, 1999). To facilitate the attainment of optimal
Journal compilation © 2007 Australian Association of Occupational Therapists
T. HOFFMANN AND N. CANTONI
occupational performance, it may be most appropriate
to address aspects of rehabilitation such as instrumental
ADL, community access, and the resumption of social,
leisure and work roles in the client’s home environment
(Ko Ko; Powell et al.). Again, home-based telehealth
applications may be able to assist rural and remote thera-
pists to provide these services without the therapist or
client needing to travel long distances.
Although there are many potential applications of
telehealth in occupational therapy, such as providing
home visits, conducting functional assessments, and plan-
ning, implementing and monitoring interventions, very
little research has explored this area. In a pilot study,
Hoffmann & Russell (unpubl. data, 2007) investigated the
feasibility and accuracy of conducting occupational ther-
apy home visits using the Internet for 40 community-
based clients who were scheduled to undergo a total hip
or knee replacement. They found that conducting home
visits using a low-bandwidth, Internet-based telehealth
system was feasible, and that the results obtained from
the Internet-based home visits were comparable to
those conducted in the traditional face-to-face manner.
Another feasibility study explored the use of televideo
technology to remotely identify home modification needs
in three houses using the case studies of three inpatients
with spinal cord injury (Sanford, Jones, Daviou, Grogg
& Butterfield, 2004). In the study by Sanford et al., the
clients were not present during the home visit. One occu-
pational therapist completed a traditional in-home assess-
ment and another therapist completed the assessment
remotely. When the accessibility problems identified by
therapists, the measurements they made, and their rec-
ommendations for modifications were compared, there
was generally a match (86.4–90%) between the remote
and in-home assessments.
In addition to using telehealth technology to conduct
remote home assessments, the other studies that have
examined the use of telehealth technology to provide
occupational therapy services have focussed primarily on
remote evaluations, with only one study focussing on
providing rehabilitation. Of note, only a few of these
studies were conducted with clients with neurological
conditions. Hoffmann et al. (in press) investigated the
validity and reliability of an Internet-based goniometer
for measuring upper limb range of motion in people
after stroke. The Internet-based goniometer was found
to be a valid measure of upper limb range of motion and
to have a high level of intra- and interrater reliability.
Malagodi, Schmeler, Shapcott & Pelleschi (1998) used
videoconferencing to enable an occupational therapist to
conduct eight seating and wheelchair mobility evalua-
tions and concluded that the general recommendations
made for each client were similar to those made after a
face-to-face consultation. Although it did not involve
occupational therapists, a small pilot study involving six
people who had had a stroke investigated the feasibility
of administering, via videoconferencing, various functional
© 2007 The Authors
TELEHEALTH AND OCCUPATIONAL THERAPY
assessments such as the Motor Activity Log, Barthel
Index, Functional Independence Measure, the nine-hole
peg test, the Fugl–Meyer Assessment, and the Jebsen–
Taylor Hand Test. The authors concluded that videocon-
ferencing could be used to perform these assessments
remotely, but that an assistant was required at the cli-
ents’ end (Winters & Winters, 2007). In another small pilot
study involving four clients, two occupational therapists
(one located with the client and one located remotely)
simultaneously scored either the Kohlman Evaluation of
Living Skills or the Canadian Occupational Performance
Measure (Dreyer, Dreyer, Shaw & Wittman, 2001). The
authors concluded that the use of telehealth systems to
score remote assessments was a promising and cost-
effective method. Hoenig et al. (2006) have developed
and evaluated a protocol for using low-bandwidth vide-
oconferencing to provide multifactorial in-home rehabili-
tation for community-based adults who were recently
prescribed a mobility aid. The rehabilitation included the
prescription of and/or training in functionally based
exercises, home-hazard assessment, provision of assis-
tive technology, environmental modifications, and edu-
cation in adaptive strategies and was provided over the
course of four visits. The authors concluded that it was
feasible to provide these intervention strategies using
telehealth technology.
The need for therapists to be able to remotely view a
client’s home environment is further highlighted by this
study’s finding that 79.5% of participants who work with
clients initially treated in non-local health facilities need
to perform home visits and home modifications before
they have met the client has significant implications for
occupational therapy practice. The purpose of a home
visit is to ensure that upon discharge, the client will be
able to perform necessary home tasks safely, and as
independently as possible. To make recommendations
regarding how to adapt activities or modify the environ-
ment to achieve this goal, the therapist needs to observe
the client perform these activities, ideally in their own
home environment (Culler, 2003). If therapists are unable
to observe a client functioning in his/her home environ-
ment, as was the case for many participants in this
study, their ability to make recommendations that will
best suit the person, their occupations and environment
may be compromised. Consequently, this may impinge
on the client’s safety and functional performance. Tele-
health technology could be used to allow the non-local
therapist to remotely view the client’s home environment
and subsequently make recommendations. Collaboration
between the local and the non-local therapists may also
be facilitated, and this may be particularly beneficial for
complex situations.
There is some consistency between participants’ responses
and the literature regarding the barriers to health service
delivery in non-metropolitan areas, namely long distances
to travel, lack of time, large workloads, and a lack of
appropriate resources such as staff and funding. Bourke
© 2007 The Authors
Journal compilation © 2007 Australian Association of Occupational Therapists
245
(2001) and Millsteed (2000) have identified the distance to
travel to appointments and the limited availability of
health professionals as significant barriers to the access
of health services by clients in rural areas. Public trans-
portation is not commonly available in rural and remote
areas (Bourke), resulting in clients having to drive them-
selves to appointments. For those who are unable to
drive, the burden of providing transport falls on carers
or significant others. For clients with neurological condi-
tions, having to travel long distances, often over poor
roads, may result in discomfort and financial burden
and clients may be reluctant to attend appointments.
According to some participants, the long distances needed
to travel to meet clients restricted the number of clients
that they were able to see in a day, further compounding
the aforementioned barriers of large workloads and lack
of time. As telehealth can reduce the time that a therapist
spends travelling, this can provide therapists with more
time to devote to other work tasks (Aas, 2002).
The distance to travel and other barriers to service
delivery were reported by participants as being responsible
for restricting their ability to provide more intensive therapy,
home-based/community therapy, and home visits to
more of their clients. The importance of home visits and
home-based has already been discussed. It is concerning
that these barriers also appear to be preventing some
clients from receiving therapy at the intensity that
their therapists believe is necessary for their optimal
rehabilitation.
Among the participants in this study, there was wide
variation in the workplace availability and use of ICT.
Telephone and email were available in the workplaces of
all participants, with the Internet and videoconferencing
equipment available to the majority of participants.
Although many participants reported workplace access to
the Internet and videoconferencing, very few participants
reported using these technologies for client assessment or
direct intervention, with participants mainly using them
for continuing professional development activities. Taylor
& Lee (2005) also found that rural occupational thera-
pists commonly used videoconferencing for continuing
professional development and were more likely to use
the technology for this purpose than for client service
delivery. An audit of the uses of the Queensland Health
videoconferencing facilities revealed that allied health
professionals’ primary use of videoconferencing was for
professional education and in-service training (Blignault,
Hornsby, Kennedy & Yellowless, 2001). Professional
isolation and limited opportunities for continuing pro-
fessional development are common barriers to the
recruitment and retention of rural occupational thera-
pists (Mills & Millsteed, 2002). The Internet, videoconfer-
encing and teleconferencing have been promoted as
means of overcoming these barriers, as they eliminate
problems caused by distance and the cost of travel
(Kennedy, Blignault, Hornsby & Yellowlees, 2001;
Sheppard & Mackintosh, 1998). However, if the use of
246
these technologies to assist in providing client services
increased, this may also assist in the recruitment and
retention of rural therapists as it may help in managing
large workloads (by reducing travel time) and reduce the
frustration experienced by therapists when they are not
able to provide an intervention because of barriers such
as distance.
Participants reported a number of perceived limita-
tions to the use of ICT for client service delivery, such as
a lack of face-to-face and hands-on contact with clients,
limited availability of ICT equipment for both therapists
and clients, concerns regarding equipment reliability,
and a lack of technical support and training. Concerns
regarding equipment reliability and lack of access to
technical support and training were also raised in the
study by Taylor & Lee (2005). It has been widely
acknowledged in the telehealth literature that the admin-
istration of certain assessments and interventions via
telehealth will always be prevented because of the
inability to have hands-on contact via the technology
(Hjelm, 2006). It is also emphasised that telehealth is not
designed to completely replace face-to-face contact with
clients, but rather should be used to increase the fre-
quency of contact between health professionals and rural
clients (Kennedy et al., 2001).
There are steps that can be taken to minimise the exist-
ence and impact of some of the limitations identified by
participants. The design and implementation of tele-
health applications require careful consideration, ensur-
ing that health professionals receive adequate education,
training, and support in the use of telehealth technology
(SARRAH, 2002). Furthermore, systems should be
designed according to the most widely available equip-
ment and information and communication services. In
this study, dial-up Internet was the most common form
of Internet connection available and not all participants
had access to videoconferencing equipment. In rural and
remote areas of Australia, an Internet bandwidth con-
nection of 18 Kbit/s is typically available (Common-
wealth of Australia, 2002). Therefore, the development
and implementation of telehealth systems that are
Internet-based and operate using a low bandwidth
Internet connection is recommended.
Limitations of study
Several limitations of this study should be acknowl-
edged. As the sample size was small and mostly mem-
bers of OT AUSTRALIA Queensland were sampled,
the results are not representative of all occupational
therapists in Queensland and other rural and remote
areas of Australia who were eligible to participate. Par-
ticipants were volunteers, suggesting that those with
strong opinions about this area of research may have
been more likely to participate. Being a self-administered
questionnaire, researchers were unable to control for the
quality of responses or clarify participants’ responses with
them (Fowler, 2002). Furthermore, answers to questions
Journal compilation © 2007 Australian Association of Occupational Therapists
T. HOFFMANN AND N. CANTONI
such as the time and distance required to travel to/from
appointments were only approximate estimates and sub-
ject to recall bias.
Future research
To facilitate the equitable provision of neurological reha-
bilitation services for clients in rural and remote areas,
future research should be targeted towards developing
and trialing viable telehealth systems that enable home-
based occupational therapy assessment, intervention,
and monitoring to be provided. Research into clients’ and
therapists’ use of and satisfaction with the systems as
well as research that examines cost-effectiveness would
also be valuable.
Conclusion
This study found that the provision of home-based
assessment and intervention is a frequent component of
occupational therapy services for clients with neuro-
logical conditions in areas of Queensland other than the
capital city, yet it is often prevented or compromised by
barriers such as the distance to clients, unsuitable road
conditions, and large workloads. Although more research
is needed, a number of preliminary research studies
have concluded that it is feasible to conduct some occu-
pational therapy evaluations and interventions using
telehealth technology. Incorporation of telehealth tech-
nology into practice may enable therapists to provide
home-based therapy while overcoming barriers such as
distance. However, the use of telehealth technology to
provide direct client services by participants in this
study was very limited, with ICT primarily being used
for continuing professional development. In order to
improve rural and remote clients’ access to occupational
therapy services, future research should be focussed on
developing and evaluating telehealth systems that ena-
ble occupational therapists to provide home-based assess-
ment, intervention, and monitoring.
Acknowledgments
The authors acknowledge with gratitude the assistance of
OT AUSTRALIA Queensland with inviting members to
participate in this study and the occupational thera-
pists who kindly completed the questionnaire.
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