Fall prevention intervention technologies: A conceptual framework and survey of the state of the art

In recent years, an ever increasing range of technology-based applications have been developed with the goal of assisting in the delivery of more effective and efficient fall prevention interventions. Whilst there have been a number of studies that have surveyed technologies for a particular sub-domain of fall prevention, there is no existing research which surveys the full spectrum of falls prevention interventions and characterises the range of technologies that have augmented this landscape. This study presents a conceptual framework and survey of the state of the art of technology-based fall prevention systems which is derived from a systematic template analysis of studies presented in contemporary research literature. The framework proposes four broad categories of fall prevention intervention system: Pre-fall prevention; Post-fall prevention; Fall injury prevention; Cross-fall prevention. Other categories include, Application type, Technology deployment platform, Information sources, Deployment environment, User interface type, and Collaborative function. After presenting the conceptual framework, a detailed survey of the state of the art is presented as a function of the proposed framework. A number of research challenges emerge as a result of surveying the research literature, which include a need for: new systems that focus on overcoming extrinsic falls risk factors; systems that support the environmental risk assessment process; systems that enable patients and practitioners to develop more collaborative relationships and engage in shared decision making during falls risk assessment and prevention activities. In response to these challenges, recommendations and future research directions are proposed to overcome each respective challenge.The Royal Society, grant Ref: RG13082

Use of Nintendo Wii Balance Board for posturographic analysis of Multiple Sclerosis patients with minimal balance impairment

Background: The Wii Balance Board (WBB) has been proposed as an inexpensive alternative to laboratory-grade Force Plates (FP) for the instrumented assessment of balance. Previous studies have reported a good validity and reliability of the WBB for estimating the path length of the Center of Pressure. Here we extend this analysis to 18 balance related features extracted from healthy subjects (HS) and individuals affected by Multiple Sclerosis (MS) with minimal balance impairment. Methods: Eighteen MS patients with minimal balance impairment (Berg Balance Scale 53.3 ± 3.1) and 18 age-matched HS were recruited in this study. All subjects underwent instrumented balance tests on the FP and WBB consisting of quiet standing with the eyes open and closed. Linear correlation analysis and Bland-Altman plots were used to assess relations between path lengths estimated using the WBB and the FP. 18 features were extracted from the instrumented balance tests. Statistical analysis was used to assess significant differences between the features estimated using the WBB and the FP and between HS and MS. The Spearman correlation coefficient was used to evaluate the validity and the Intraclass Correlation Coefficient was used to assess the reliability of WBB measures with respect to the FP. Classifiers based on Support Vector Machines trained on the FP and WBB features were used to assess the ability of both devices to discriminate between HS and MS. Results: We found a significant linear relation between the path lengths calculated from the WBB and the FP indicating an overestimation of these parameters in the WBB. We observed significant differences in the path lengths between FP and WBB in most conditions. However, significant differences were not found for the majority of the other features. We observed the same significant differences between the HS and MS populations across the two measurement systems. Validity and reliability were moderate-to-high for all the analyzed features. Both the FP and WBB trained classifier showed similar classification performance (>80%) when discriminating between HS and MS. Conclusions: Our results support the observation that the WBB, although not suitable for obtaining absolute measures, could be successfully used in comparative analysis of different populations

The Use of Gaming Technology in the Rehabilitation of Patients Following Total Knee Replacement Surgery

Home-based rehabilitation following total knee replacement (TKR) surgery can be as effective as clinic-based or in-patient rehabilitation. The use of the Nintendo Wii, Wii Balance Board and Wii-fit software was postulated as a novel rehabilitation tool that could add additional focus on balance and proprioception. The aim of this thesis was to investigate the effectiveness of this novel rehabilitation tool, both as a device for measuring balance outcomes and for rehabilitation following TKR surgery. The pilot studies investigated the validity and reliability of the Nintendo Wii-fit software, the relationship of balance with function in the arthritic population and the ability of this elderly population to use computer technology. The RCT-POWER study was a trial of 128 patients undergoing primary total knee replacement, randomised at 6 weeks post-TKR surgery to 3 months of usual care or using the Wii-Fit at home. The primary outcome was the change in WOMAC total score from week 6 to 18 weeks and 1 year. The results of this thesis are relevant for clinical practice, providing evidence for the use of affordable technology for the rehabilitation of patients at home. The intervention improved functional outcomes as measured by WOMAC and also adherence to the rehabilitation protocol

Sit still and pay attention: Using the Wii Balance-Board to detect lapses in concentration in children during psychophysical testing.

During psychophysical testing, a loss of concentration can cause observers to answer incorrectly, even when the stimulus is clearly perceptible. Such lapses limit the accuracy and speed of many psychophysical measurements. This study evaluates an automated technique for detecting lapses based on body movement (postural instability). Thirty-five children (8-11 years of age) and 34 adults performed a typical psychophysical task (orientation discrimination) while seated on a Wii Fit Balance Board: a gaming device that measures center of pressure (CoP). Incorrect responses on suprathreshold catch trials provided the "reference standard" measure of when lapses in concentration occurred. Children exhibited significantly greater variability in CoP on lapse trials, indicating that postural instability provides a feasible, real-time index of concentration. Limitations and potential applications of this method are discussed

Balance Board-based System for Fall Prevention in Older Adults

O aumento da qualidade de vida no século passado fez crescer a esperança média de vida que levou ao envelhecimento da populção. Com esta mudança, problemas relacionados com a idade são cada vez mais comuns. Um destes problemas são as quedas as suas graves consequências nos idosos. Como a idade deteriora sistemas biológicos que intervêm no mantimento do equilíbrio, quedas tornam-se mais frequentes e mais severas. Os programas de prevenção de quedas contém vários métodos que se complementam. Um deles é o exercício que melhora o equilíbrio em adultos mais velhos, diminuindo assim o risco de queda, assim como também o fortalecimento da massa muscular, atenuando as consequências das quedas. No entanto, é difícil motivar os idosos para praticar exercícios saudáveis de forma regular.Foi demonstrado que novos e acessíveis equipamentos que captam movimentos trazem maior motivação à fisioterapia ao introduzir ambientes descontraídos e divertidos. Um destes, a Balance Board da Nintendo Wii (WBB), usa quatro sensores de pressão que medem o centro de pressão (COP) de um utilizador e foi provado que este cálculo é útil para ajudar terapeutas a analisar o progresso de um paciente. Muitos destes aparelhos foram criados para propósitos de entretenimento, criando exergames que são jogos de vídeo em que o jogador precisa de fazer exercício para jogar. Orientados à terapia, exergames podem ser mais motivantes para os pacientes que métodos tradicionais de reabilitação para os pacientes.O principal objectivo desta dissertação é estudar a relação entre seniores e exergames interactivos de modo a proporcionar uma solução para a sua falta de motivação para a práctica regular de exercício. É também pretendido explorar as capacidades da WBB para avaliar automaticamente o equilíbrio do jogador, através de métricas relacionadas com o COP para ajudar a monitorização dos pacientes. Uma aliança entre técnicas de desenvolvimento de jogos com exercícios para a prevenção de quedas poderá motivar idosos devido à combinação entre o prazer de jogar jogos de vídeo e a necessidade de promover o equilíbrio.Dois exergames interactivos foram desenvolvidos. Estes jogos requerem o uso da WBB para realizar exercícios retirados de programas para a prevenção de quedas, como o Otago Exercise Programme ou o Fitness and Mobility Exercise (FAME), como também de escalas de avaliação do equilíbro, como a Berg Balance Scale. Enquanto os séniores jogos, o sistema usa as capacidades da WBB para seguir o COP e calcula métricas para a avaliação do equilíbrio usadas por fisioterapeutas, nomeadamente a velocidade média e oscilação total do COP. Com estes dados, é possível gerar gráficos de grande utilidade que podem ajudar terapeutas com a análise, que são o caminho, amplitude ao longo do tempo e mapa de frequência do COP.O sistem foi avaliado a duas sessões de teste com um total de 17 seniores voluntários, onde estes tiveram oportunidade de interagir com os jogos. Apesar de a maior parte deles não ter compreendido totalmente a mecânica e lógica do jogos à primeira tentativa, todos afirmram que gostaram da experiência, gostariam de jogar regularmente e que os exergames os motivam para fazer exercício. A solução desenvolvida pode encaminhar os adultos para a prática de exercício regular e potencialmente diminuir do risco de queda enquanto ao mesmo tempo oferece aos fisioterapeutas um meio para monitorizar o equilíbrio dos seus pacientes.The increase in quality of life over the past century led to the growth of life expectancy, which turns population increasingly older. With this change, age related problems are more common. One of these problems is falls and their grave consequences. As age degrades biological elements that control body balance, falls become more frequent and more severe. Fall prevention programes usually integrate several complementary methods. One of them is exercise that improves balance in older adults, decreasing fall risk, but also strengthens the body, mitigating fall consequences. However, motivating seniors to do healthy exercises is difficult.Recent affordable motion sensing devices have been shown to bring motivation as they turn physiotherapy sessions into entertaining and engaging interactive environments. One of those, the Nintendo Wii Balance Board System (WBB), uses four pressure sensors that measure the user's center of pressure (COP) which computation has been proved to be useful in helping the therapists evaluate their patient's balance. Many of these devices were created with entertainment purposes through exergames, which are video games where the player needs to do exercise to play. When oriented to therapy, exergames can be more motivating for patients than traditional rehabilitation methods.The main objective of this dissertation is to study the relation between older adults and interactive exergames to provide a solution for their poor motivation towards regular exercise practice. In addition, the WBB capabilities are explored in order to evaluate the player's balance automatically through COP related metrics, which can help supervisors monitor patients. An alliance of game development techniques with fall-prevention exercises may motivate older adults as it combines the pleasure of playing video games with the need to promote balance.Two interactive exergames were developed. These games require using the WBB to perform exercises that are part of the main fall-prevention programs, such as Otago Exercise Programme or Fitness and Mobility Exercise (FAME), and balance assessment scales as well, such as Berg Balance Scale. While the senior plays the game, the system uses the WBB capabilities to track the COP and compute balance assessment metrics used by physiotherapists, namely the COP's mean velocity and total oscillation. This data can be further processed and COP's path, amplitude over time and frequency maps can be generated.The system was evaluated with two separate set of tests with a total of 17 volunteers, in which they had the chance to interacted with the games. Although most of them did not fully understand the games' mechanics and logic t their first attempt, all of them stated they enjoyed the experience, would like to play regularly and that the exergames motivated them to do exercise. The developed solution can hopefully lead seniors to increase the practice of physical activity and eventually decrease fall risk while providing physiotherapists a mean to monitor the evolution of balance of their patients

Cardiovascular Effects and Enjoyment of Exer-Gaming in Older Adults

Background: A physically active lifestyle provides a variety of health benefits. However, physical activity may decline with age. Currently, there are 40 million older adults, representing 13.1% of the population in the United States. National surveys report that only 30% of older adults perform adequate amounts of physical activity. The lack of daily physical activity (PA) can lead to an increased risk of chronic disease. Exer-gaming (EG) has been successful in increasing PA in children and young adults in a fun and enjoyable manner, but the use of EG with older adults has not been well studied. Purpose: To quantify the cardiovascular responses, the enjoyment, and the untoward physical discomforts to a 15 minute trial of EG (Nintendo Wii Tennis) in healthy, older adults. Methods: A quasi-experimental design using a convenience sample of 34 self-reported healthy older adults from an independent living retirement community in Southeastern Pennsylvania completed the study. Serial measurements of heart rate, blood pressures (systolic, diastolic, and mean), rate-pressure product, and perceived exertion were taken at 5 minute intervals beginning at rest, standing, playing Wii tennis and post play recovery. Enjoyment was measured post Wii play and a 48 hour post questionnaire was provided. Analysis of the data included the use of descriptive statistics and general linear modeling of repeated measures. Results: 15 minutes of exercise gaming (Nintendo Wii Tennis), moderately increased heart rate (p\u3c0.001), blood pressures (p\u3c0.001) and perceived exertion (p\u3c0.0001) compared to rest. This level of activity corresponded to an age predicted maximum heart rate range of 64%. No differences in cardiovascular variables occurred between genders. Beta-blockade suppressed the heart rate and rate pressure product. All subjects completed EG tennis without reporting fatigue with 86% enjoying the experience with few physical discomforts and arrhythmias. Conclusions: Nintendo Wii EG technology (tennis) induces a moderate intensity cardiovascular stress in an overall enjoyable manner among health, older adults

Using the Microsoft Kinect to assess human bimanual coordination

Optical marker-based systems are the gold-standard for capturing three-dimensional (3D) human kinematics. However, these systems have various drawbacks including time consuming marker placement, soft tissue movement artifact, and are prohibitively expensive and non-portable. The Microsoft Kinect is an inexpensive, portable, depth camera that can be used to capture 3D human movement kinematics. Numerous investigations have assessed the Kinect\u27s ability to capture postural control and gait, but to date, no study has evaluated it\u27s capabilities for measuring spatiotemporal coordination. In order to investigate human coordination and coordination stability with the Kinect, a well-studied bimanual coordination paradigm (Kelso, 1984, Kelso; Scholz, & Schöner, 1986) was adapted. ^ Nineteen participants performed ten trials of coordinated hand movements in either in-phase or anti-phase patterns of coordination to the beat of a metronome which was incrementally sped up and slowed down. Continuous relative phase (CRP) and the standard deviation of CRP were used to assess coordination and coordination stability, respectively.^ Data from the Kinect were compared to a Vicon motion capture system using a mixed-model, repeated measures analysis of variance and intraclass correlation coefficients (2,1) (ICC(2,1)).^ Kinect significantly underestimated CRP for the the anti-phase coordination pattern (p \u3c.0001) and overestimated the in-phase pattern (p\u3c.0001). However, a high ICC value (r=.097) was found between the systems. For the standard deviation of CRP, the Kinect exhibited significantly higher variability than the Vicon (p \u3c .0001) but was able to distinguish significant differences between patterns of coordination with anti-phase variability being higher than in-phase (p \u3c .0001). Additionally, the Kinect was unable to accurately capture the structure of coordination stability for the anti-phase pattern. Finally, agreement was found between systems using the ICC (r=.37).^ In conclusion, the Kinect was unable to accurately capture mean CRP. However, the high ICC between the two systems is promising and the Kinect was able to distinguish between the coordination stability of in-phase and anti-phase coordination. However, the structure of variability as movement speed increased was dissimilar to the Vicon, particularly for the anti-phase pattern. Some aspects of coordination are nicely captured by the Kinect while others are not. Detecting differences between bimanual coordination patterns and the stability of those patterns can be achieved using the Kinect. However, researchers interested in the structure of coordination stability should exercise caution since poor agreement was found between systems

Design and Development of ReMoVES Platform for Motion and Cognitive Rehabilitation

Exergames have recently gained popularity and scientific reliability in the field of assistive computing technology for human well-being. The ReMoVES platform, developed by the author, provides motor and cognitive exergames to be performed by elderly or disabled people, in conjunction with traditional rehabilitation. Data acquisition during the exercise takes place through Microsoft Kinect, Leap Motion and touchscreen monitor. The therapist is provided with feedback on patients' activity over time in order to assess their weakness and correct inaccurate movement attitudes. This work describes the technical characteristics of the ReMoVES platform, designed to be used by multiple locations such as rehabilitation centers or the patient's home, while providing a centralized data collection server. The system includes 15 exergames, developed from scratch by the author, with the aim of promoting motor and cognitive activity through patient entertainment. The ReMoVES platform differs from similar solutions for the automatic data processing features in support of the therapist. Three methods are presented: based on classic data analysis, on Support Vector Machine classification, and finally on Recurrent Neural Networks. The results describe how it is possible to discern patient gaming sessions with adequate performance from those with incorrect movements with an accuracy of up to 92%. The system has been used with real patients and a data database is made available to the scientific community. The aim is to encourage the dissemination of such data to lay the foundations for a comparison between similar studies

Technology Innovation Enabling Falls Risk Assessment in a Community Setting

Approximately one in three people over the age of 65 will fall each year, resulting in significant financial, physical, and emotional cost on the individual, their family, and society. Currently, falls are managed using on-body sensors and alarm pendants to notify others when a falls event occurs. However these technologies do not prevent a fall from occurring. There is now a growing focus on falls risk assessment and preventative interventions. Falls risk is currently assessed in a clinical setting by expert physiotherapists, geriatricians, or occupational therapists following the occurrence of an injurious fall. As the population ages, this reactive model of care will become increasingly unsatisfactory, and a proactive community-based prevention strategy will be required. Recent advances in technology can support this new model of care by enabling community-based practitioners to perform tests that previously required expensive technology or expert interpretation. Gait and balance impairment is one of the most common risk factors for falls. This paper reviews the current technical and non-technical gait and balance assessments, discusses how low-cost technology can be applied to objectively administer and interpret these tests in the community, and reports on recent research where body-worn sensors have been utilized. It also discusses the barriers to adoption in the community and proposes ethnographic research as a method to investigate solutions to these barriers