Telemedical percussion: objectifying a fundamental clinical examination technique for telemedicine

Abstract

Purpose: While demand for telemedicine is increasing, patients are currently restricted to tele-consultation for the most part. Fundamental diagnostics like the percussion still require the in person expertize of a physician. To meet today's challenges, a transformation of the manual percussion into a standardized, digital version, ready for telemedical execution is required.

Methods: In conjunction with a comprehensive telemedical diagnostic system, in which patients can get examined by a remote-physician, a series of three robotic end-effectors for mechanical percussion were developed. Comprising a motor, a magnetic and a pneumatic-based version, the devices strike a pleximeter to perform the percussion. Emitted sounds were captured using a microphone-equipped stethoscope. The 84 recordings were further integrated into a survey in order to classify lung and non-lung samples.

Results: The study with 21 participants comprised physicians, medical students and non-medical-related raters in equal parts. With 71.4% correctly classified samples, the ventral motorized device prevailed. While the result is significantly better compared to a manual or pneumatic percussion in this very setup, it only has a small edge over the magnetic devices. In addition, for all ventral versions non-lung regions were rather correctly identified than lung regions.

Conclusion: The overall setup proves the feasibility of a telemedical percussion. Despite the fact, that produced sounds differ compared to today's manual technique, the study shows that a standardized mechanical percussion has the potential to improve the gold standard's accuracy. While further extensive medical evaluation is yet to come, the system paves the way for future uncompromised remote examinations.

Keywords: Auscultation; Percussion; Robotic examination; Robotic percussion; Tele-diagnostic; Telemedicine.

Fig. 1

Left: Ivory pelximeter with handles used to transfer the strikes during a percussion onto the patient’s tissue [8]. Right: Sibson’s percussor-pleximeter, a percussion device with an integrated pleximeter, allowing for higher standardized diagnostics [8]

Fig. 2

Left: Photograph of the examination cabin. White circles indicate the distinct examination modules. Right: Detail shot, showing the revolver-like fixture at the robotic arm of module 3 with the attached palpation and auscultation device, as well as the magnetic percussion end-effector during evaluation

Fig. 3

Inner workings of the three different percussion instruments. Picture a shows the spring-loaded motorized version, picture b depicts the transistor controlled solenoid and picture c displays the pneumatic percussion instrument, driven by an external supply of compressed air

Fig. 4

Percussion points on the ventral (left) and dorsal (right) patient side. The lung region is highlighted. Auscultation was always carried out dosal and in close proximity to the percussion end-effector

Fig. 5

Device abbreviations—MAN manual percussion, MOT-D mechanic device with dorsal percussion and auscultation, MOT-V mechanic device with ventral percussion and dorsal auscultation, MAGN-D magnetic device with dorsal percussion and auscultation, MAGN-V magnetic device with ventral percussion and dorsal auscultation, PNEU-D pneumatic device with dorsal percussion and auscultation, PNEU-V pneumatic device with ventral percussion and dorsal auscultation, the color scheme from A and B is also used in C, in B the symbols mark the mean and the whiskers the standard deviation on the respective axis/**p value < 0.01, *p value < 0.05, n.s. p value $\ge$ 0.05 in Friedman test with Wilcoxon rank sum test as post-hoc analysis, p values are adjusted by Bonferroni correction