A systematic approach towards designing low-cost motor and cognitive rehabilitation systems after...
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Sergi Bermúdez i Badia
Inv. Assist. Prof., Universidade da Madeira
Marie Curie Research Fellow, Madeira – ITI
2050
*United Nations Population Fund 2012
• The world population is ageing dramatically
• In Europe ~20% of the population is over 60; it will be 30+% by 2050.2
• One of the main causes of permanent disability in older adults that consumes 2-4% of total healthcare costs worldwide.
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• The number of strokes will increase during the next 40 years.
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• It will be difficult to manage the sharp rise of social and healthcare costs.
1Donnan et al., Lancet 2008;
2Howard & Goff, Ann. N.Y. Acad. Sci 2013
Peripheral manipulation of the skeletal-motor system is expensive, boring, treats the sequels but not the source of the problem…
Dobkin, Nat Clin Pract Neurol 2008
1. Treatment frequency and intensity correlate with recovery
(Kwakkel et al., 2004; Sonoda, Saitoh, Nagai, Kawakita, & Kanada,
2004).
Low cost technology for extended deployment
2. Movement practice and repetition play a fundamental role in
recovery (Karni et al., 1995).
Building requirements into game mechanics
3. Specificity of rehabilitation training with respect to the deficits and
required functional outcomes has an impact on recovery (Krakauer
2006).
Accessible interface technology and task personalization
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VE can provide:
- Fully controlled environments
- Minimally supervised intensive training
- Task-specific movement reiteration
- Individualized training
- Feedback for reward and motivation
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1- Virtual Reality technology: - 3D virtual environments - Head Mounted Displays (Oculus Rift, Vuzix)
2- Patient monitoring: - Eye tracking (EyeTribe, Tobii) - Autonomic System responses (Bitalino) - Face tracking (Face API) 3- Accessible Rehabilitation: - Movement kinematics (kinect, wii) - BCI-EEG (g.MobiLab, OpenVibe, BCI2000, EMOTIV) 4- EMG driven Neuro-Robotic orthosis (mPower1000) 5- Augmented Reality (AR) and custom tracking through AnTS 6- We provide it as open and freely available software for research at http://neurorehabilitation.m-iti.org
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Training paradigm:
- Goal oriented and repetitive actions
- Bimanual training (non-paretic arm
support)
- Parameterized (flying speed,
turning speed, acceptance radius,
distance between objects)
Motivation:
- Embedded in a game
- Extensive visual and sound
feedback
- Automatic computation of training
parameters (Avoid failure and
frustration)
Quantify performance
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- Optimal performance at intermediate stress levels - We use the Yerkes & Dodson law to optimize time to the average performance of the user
* Yerkes, R.M. and J.D. Dodson, 1908
* Yerkes, R.M. and J.D. Dodson, 1908
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- Flow is “a state of peak enjoyment, energetic focus, and creative concentration by people engaged in adult play” - Balance user skills with challenge using our psychometric model
* Csikszentmihalyi, M. 1975
* Csikszentmihalyi, M. 1975
A study with 10 healthy participants has
shown that the NTT captures precise
quantitative kinematic information during a NTT training session, including:
• Range of Movement (ROM)
• Movement smoothness • Arm coordination • Arm contribution to task
Bermúdez i Badia, Stroke Research & Treat, 2012
s t a d s*t s*a s*d t*a t*d a*d s2 t2 a2 d2 Movement Smoothness Range of Motion
Arm Displacement Arm coordination
Kinematic measure = c0 + c1*speed + c2*turning + c3*acceptance + c4*distance
+ c5*speed*turning + c6*speed*acceptance + c7*speed*distance
+ c8*turning*acceptance + c9*turning*distance
+ c10*distance*acceptance + c11*speed2 + c12*turning2 + c13*acceptance2
+ c14*distance2
- Not all parameters contribute to all movement kinematic measures
- We have a quantitative way of adapting parameters depending on a higher level
desired kinematic training
• Cognitive domain is not always considered. • ADL’s are mostly cognitive and motor (dual-task).
RGS (Cameirão et al., 2011)
NTT (Bermúdez i Badia & Cameirão, 2012)
What do we know about cognitive demands of these tasks?
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• Cognitive rehabilitation is mostly performed with “paper and pencil tools”.
• Based on “tradition”, not
necessarily scientific evidence.
• Traditional tasks lack ecological validity.
• There is no framework for how to design and select tasks for cognitive rehabilitation.
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* Taxonomy Revised (Anderson et al., 2001) * Toulouse – Piéron task (Toulouse et
al., 2004)
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Creating ecologically valid
Activities of Daily Living (ADLs)
• Attention
simulated supermarket, post
office, bank, pharmacy
• Executive functions
elementary instructions,
problem solving tasks
• Visuospatial orientation
navigation through simulated
city
Vourvopoulos et al. International Conference on Advances in Computer Entertainment Technology (ACE’14).
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Inclusion criteria: • Absence of hemi-spatial neglect;
• Sufficient cognitive capacity (MMSE) ≥ 15 (Folstein et al, 1975 English version of Warrior et al., 1994);
• Ability to be seated;
• Education ≥ 4th class or read and write;
• Motivation to participate in the study.
Participants: • 18 (9 experimental + 9 control), with ages between 34 – 90 years old
• 10 female and 8 male
• Time after stroke: 3 months to 14 years
• Localization: 9 left hemisphere + 9 right hemisphere
• 15 participants had no experience with computers
•with prof. Luísa Soares (UMa) Dra. Manuela Barros (SESARAM)
Dr. Rafael Freitas (SESARAM) Dra. Teresa Gois (SESARAM)
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12 sessions of 20 min of cognitive training (~ 1 month) on top of conventional therapy with pre and post assessment.
• Experimental group: VR based simulation of ADL
• Control group: Cognitive stimulation using traditional tools (puzzles, paper and pencil tasks, etc)
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• Addenbrooke's cognitive examination - ACE-R - assesses: attention, memory, verbal fluency, language and visual-spatial orientation.
• Trail making test A and B - evaluates attention, sequencing of stimuli, visual search, information processing, eye-hand coordination, etc.
• Layout of pictures - ability to organize and sequence a story.
• Stroke Impact Scale - SIS – subjective evaluation of strength, hand function, memory, emotion, mobility, ADL’s, communication and social participation.
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* Bold indicates p < 0.05 matched-pairs Wilcoxon test
Experimental Group Control Group
Pre Post Pre Post
ACE-R - Total Median 72 81 (+9) 66 69 IQR 15 19 27 20
MMSE Median 23 29 (+6) 23 26 IQR 6 4 6 6
(ACE-R) Attention & Orientation
Median 15 18 (+3) 14 16 IQR 3 2 5 5
(ACE-R) Memory Median 15 18 (+3) 18 18 IQR 5 7 9 9
(ACE-R) Verbal Fluency Median 5 6 6 5 (-1) IQR 4 4 4 3
(ACE-R) Language Median 22 24 (+2) 19 21 IQR 2 5 6 8
(ACE-R) Visuo-spatial Median 12 14 12 14 IQR 7 2 6 9
Layout of pictures Median 2 4 (+2) 2 2 IQR 2 5 3 3
* Bold indicates p < 0.05 matched-pairs Wilcoxon test
* Bold indicates p < 0.05 matched-pairs Wilcoxon test
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* Bold indicates p < 0.05 matched-pairs Wilcoxon test
* Bold indicates p < 0.05 matched-pairs Wilcoxon test
* Bold indicates p < 0.05 matched-pairs Wilcoxon test
Experimental Group Control Group
Pre Post Pre Post
Memory Median 62,5 71,88 (+9,38) 56,25 62,5 (+6.25)
IQR 37,5 33,48 37,52 32,82
Emotional Estability
Median 75 83,33 (+8.33) 58,33 66,67
IQR 29,15 12,44 27,78 27,78
Comunication Median 75 85,71 67,86 67,86 IQR 30,35 32,15 37,51 39,29
ADLs Median 50 56,25 43,75 45,337 IQR 42,71 37,5 38,54 33,35
Social Participation
Median 63,89 66,67 (+2.78) 36,11 50 (+13.18)
IQR 43,17 29,8 22,21 16,66
Total Recovery Median 50 70 (+20) 40 60 IQR 15 25 15 30
• A close dialog between health practitioners – neuroscientists – technologists is necessary
• Our systems are not the end product, are the hypotheses
• Hypotheses need validation impact assessment
• Game / training mechanics need to include:
• Game parameters need to be automatically personalized
• Challenge vs. skill needs to be quantified and well understood
• Stress levels need to be controlled to ensure maximal performance and consequent maximal learning
• Consider both motor and cognitive aspects
• Relation with Activities of Daily Living
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Sergi Bermúdez i Badia (Assist. Prof)
Mónica S. Cameirão (Assist. Prof)
Ana Lúcia dos Santos Faria (PhD student)
Athanasios Vourvopoulos (PhD student)
John Edison Muñoz (PhD student)
Teresa Paulino (Research assistant)
Afonso Gonçalves (PhD student)
Andreia Andrade, MSc student Psychology (join thesis with Luísa Soares) Júlio Alves, MSc student Informatics (join thesis with VisLab, IST-Lisbon) Davide Neves, MSc student Informatics Miguel Sousa, MSc student Telecommunications and Networks (join thesis with Luís Gomes) André Ferreira, MSc student Informatics Rúben Jardim, MSc student Informatics
University of Pittsburgh Department of Occupational Therapy
Quality of Life Technologies Center http://www.cmu.edu/qolt Carnegie Mellon University
Daniel P. Siewiorek Asim Smailagic
Scott Bleakley
Myomo Inc http://www.myomo.com
Steve Kelly Ela Lewis
SESARAM - www.sesaram.pt Serviço de Saúde da RAM
Dra. Manuela Barros Dr. Rafael Freitas Dra. Teresa Gois
Dr. Jean-Claude Fernandes Dr. Gil Bebiano
Dr. Rafael Macedo
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