Telerehabilitation: State-of-the-Art from an Informatics Perspective

Rehabilitation service providers in rural or underserved areas are often challenged in meeting the needs of their complex patients due to limited resources in their geographical area. Recruitment and retention of the rural clinical workforce are beset by the ongoing problems associated with limited continuing education opportunities, professional isolation, and the challenges inherent to coordinating rural community healthcare. People with disabilities who live in rural communities also face challenges accessing healthcare. Traveling long distances to a specialty clinic for necessary expertise is troublesome due to inadequate or unavailable transportation, disability specific limitations, and financial limitations. Distance and lack of access are just two threats to quality of care that now being addressed by the use of videoconferencing, information exchange, and other telecommunication technologies that facilitate telerehabilitation. This white paper illustrates and summarizes clinical and vocational applications of telerehabilitation. We provide definitions related to the fields of telemedicine, telehealth, and telerehabilitation, and consider the impetus for telerehabilitation. We review the telerehabilitation literature for assistive technology applications, pressure ulcer prevention, virtual reality applications, speech-language pathology applications, seating and wheeled mobility applications, vocational rehabilitation applications, and cost-effectiveness. We then discuss external telerehabilitation influencers, such as the positions of professional organizations. Finally, we summarize clinical and policy issues in a limited context appropriate to the scope of this paper. Keywords: Telerehabilitation, Telehealth,Telemedicine, Telepractic

Telerehabilitation: State-of-the-Art from an Informatics Perspective

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Design, Fabrication, and Control of an Upper Arm Exoskeleton Assistive Robot

Stroke is the primary cause of permanent impairment and neurological damage in the United States and Europe. Annually, about fifteen million individuals worldwide suffer from stroke, which kills about one third of them. For many years, it was believed that major recovery can be achieved only in the first six months after a stroke. More recent research has demonstrated that even many years after a stroke, significant improvement is not out of reach. However, economic pressures, the aging population, and lack of specialists and available human resources can interrupt therapy, which impedes full recovery of patients after being discharged from hospital following initial rehabilitation. Robotic devices, and in particular portable robots that provide rehabilitation therapy at home and in clinics, are a novel way not only to optimize the cost of therapy but also to let more patients benefit from rehabilitation for a longer time. Robots used for such purposes should be smaller, lighter and more affordable than the robots currently used in clinics and hospitals. The common human-machine interaction design criteria such as work envelopes, safety, comfort, adaptability, space limitations, and weight-to-force ratio must still be taken into consideration.;In this work a light, wearable, affordable assistive robot was designed and a controller to assist with an activity of daily life (ADL) was developed. The mechanical design targeted the most vulnerable group of the society to stroke, based on the average size and age of the patients, with adjustability to accommodate a variety of individuals. The novel mechanical design avoids motion singularities and provides a large workspace for various ADLs. Unlike similar exoskeleton robots, the actuators are placed on the patient\u27s torso and the force is transmitted through a Bowden cable mechanism. Since the actuators\u27 mass does not affect the motion of the upper extremities, the robot can be more agile and more powerful. A compact novel actuation method with high power-to-weight ratio called the twisted string actuation method was used. Part of the research involved selection and testing of several string compositions and configurations to compare their suitability and to characterize their performance. Feedback sensor count and type have been carefully considered to keep the cost of the system as low as possible. A master-slave controller was designed and its performance in tracking the targeted ADL trajectory was evaluated for one degree of freedom (DOF). An outline for proposed future research will be presented

Development and evaluation of a haptic framework supporting telerehabilitation robotics and group interaction

Telerehabilitation robotics has grown remarkably in the past few years. It can provide intensive training to people with special needs remotely while facilitating therapists to observe the whole process. Telerehabilitation robotics is a promising solution supporting routine care which can help to transform face-to-face and one-on-one treatment sessions that require not only intensive human resource but are also restricted to some specialised care centres to treatments that are technology-based (less human involvement) and easy to access remotely from anywhere. However, there are some limitations such as network latency, jitter, and delay of the internet that can affect negatively user experience and quality of the treatment session. Moreover, the lack of social interaction since all treatments are performed over the internet can reduce motivation of the patients. As a result, these limitations are making it very difficult to deliver an efficient recovery plan. This thesis developed and evaluated a new framework designed to facilitate telerehabilitation robotics. The framework integrates multiple cutting-edge technologies to generate playful activities that involve group interaction with binaural audio, visual, and haptic feedback with robot interaction in a variety of environments. The research questions asked were: 1) Can activity mediated by technology motivate and influence the behaviour of users, so that they engage in the activity and sustain a good level of motivation? 2) Will working as a group enhance users’ motivation and interaction? 3) Can we transfer real life activity involving group interaction to virtual domain and deliver it reliably via the internet? There were three goals in this work: first was to compare people’s behaviours and motivations while doing the task in a group and on their own; second was to determine whether group interaction in virtual and reala environments was different from each other in terms of performance, engagement and strategy to complete the task; finally was to test out the effectiveness of the framework based on the benchmarks generated from socially assistive robotics literature. Three studies have been conducted to achieve the first goal, two with healthy participants and one with seven autistic children. The first study observed how people react in a challenging group task while the other two studies compared group and individual interactions. The results obtained from these studies showed that the group interactions were more enjoyable than individual interactions and most likely had more positive effects in terms of user behaviours. This suggests that the group interaction approach has the potential to motivate individuals to make more movements and be more active and could be applied in the future for more serious therapy. Another study has been conducted to measure group interaction’s performance in virtual and real environments and pointed out which aspect influences users’ strategy for dealing with the task. The results from this study helped to form a better understanding to predict a user’s behaviour in a collaborative task. A simulation has been run to compare the results generated from the predictor and the real data. It has shown that, with an appropriate training method, the predictor can perform very well. This thesis has demonstrated the feasibility of group interaction via the internet using robotic technology which could be beneficial for people who require social interaction (e.g. stroke patients and autistic children) in their treatments without regular visits to the clinical centres

Development of an Integrated Telerehabilitation Information Management System to Support Remote Wheelchair Prescription

Information technology (IT) is central in providing Telerehabilitation (TR), which enables people with disabilities access to limited number of qualified practitioners with specialty expertise, especially at rural areas. Prior to 2008, most TR utilized non-integrated IT systems to provide its basic infrastructure. Using this approach, data management has to be done manually over multiple non-integrated systems, increasing the possibility of outdated or missing data. An integrated system that is open, flexible, extensible, and cost-effective was designed and developed as a solution to mitigate this problem. The work described in this dissertation elaborates the process of developing such system, called the Versatile and Integrated System for Telerehabilitation (VISYTER). VISYTER was intended to become a platform that is capable of delivering any TR, and was first used to support Remote Wheelchair Prescription (RWP), a TR effort to support clinicians in rural Pennsylvania to prescribe wheeled mobility and seating devices. The development process of VISYTER consisted of three main phases: identification and verification of requirements, validation, and evaluation. The requirement identification and verification phase involved a group of expert clinicians from RWP with the purpose of identifying the requirement of the system to support RWP: a system that can provide real-time teleconsultation and documentation support for prescribing a wheeled mobility intervention. Validation studies were conducted with help from ten individuals, including physicians, clinicians, and suppliers participated to validate VISYTER in their workplaces. All participants agreed that VISYTER can be used to properly support both the teleconsultation and documentation phase of RWP. Afterward, the usability of VISYTER was evaluated through a comparison study with a commonly utilized videoconferencing system in TR, POLYCOM. Twenty-six clinicians participated in a counterbalanced experimental study to measure the difference in usability for completing client assessment tasks using both systems. The study found VISYTER to be more efficient and less prone to error when compared to POLYCOM. Based on these findings, the study concluded that an integrated system could improve the usability TR delivery when compared to non-integrated systems approach

Usability engineering in the design and evaluation of a functional electrical stimulation system for upper limb rehabilitation

Chronic physical impairment of the hemiplegic upper limb (UL) is seen in an estimated 50-70% of stroke patients, who place a high priority on regaining upper limb function. Current therapy is insufficiently intensive, often not task-oriented and hence poorly aligned with the evidence base. Functional electrical stimulation (FES) has the potential to not only increase the intensity of task-focused therapy, but also provide certain unique features, notably direct excitation of lower motor neurons. However, current FES systems are limited in their functionality and/or difficult to use. Systems are also poorly aligned to therapists’ ways of working and uptake remains limited. To address these problems, a novel FES technology (UL FES Rehab Tool) has been developed. The control system design is reported in Sun, (2014). The aims of my thesis were to: 1) design a Graphical User Interface (GUI) that would enable therapists to quickly and easily set up an individually tailored library of FES tasks for each patient; 2) evaluate the usability and functionality of the UL FES Rehab Tool(software and hardware) in both laboratory (lab) and clinical settings. An iterative, mixed methods, five-phase usability engineering approach was used to design and evaluate the UL FES Rehab Tool. Phases one to three incorporated identification of therapists’ requirements, a user ‘assisted walkthrough’ of the software with expert and novice FES users and ‘rapid prototyping’ of the full system, using healthy participants. Further usability testing of the software & hardware was conducted in phase four with 1 physiotherapist and 6 patients, (total of 24 visits), in the chronic stage post-stroke. The work demonstrated in detail, for the first time, the impact of therapist involvement in the design of novel rehabilitation technology. To address therapists’ focus on setup time, using the phase four data set, a novel model to predict setup time was devised. This model was able to explain 51% of the variance in setup time based on two parameters, task complexity and patient impairment. Finally, in phase five, a summative usability evaluation of the final prototype was carried out in 2 sub-acute stroke units. Four therapists and 1 rehabilitation assistant used the UL FES Rehab Tool with 6 patients in the acute stage post-stroke. The UL FES Rehab Tool enabled all therapists and one therapy assistant to effectively deliver FES assisted upper limb task-oriented therapy to a range of stroke patients (Fugl-Meyer scores 8–65). The usability methods effectively captured objective and subjective feedback from therapists and patients. However the previous setup time model was unable to predict setup time, suggesting other factors were important in a clinical setting. Although participant numbers were low, the results suggested therapists’ predisposition to using technology and post-training confidence in using the technology may influence their willingness to engage with novel rehabilitation technologies. This study is the first to describe in detail the impact of a usability engineering approach on the design of a complex upper limb rehabilitation technology from early stage design to clinical evaluation. These methods can be generalised to other studies seeking to explore the usability of new forms of rehabilitation technologies