Technology Related Research @ Bruyère

Continuing CareFrank Knoefel

Jeff JutaiHillel Finestone

2012/06/14

Bruyere Continuing Care: BIGR Rounds

Objectives

1. Describe three of the main areas of focus for technology research at Bruyère

2. Explain how technology can help improve the quality of care at Bruyère and quality of life of patients

3. Identify opportunities for participating in technology research at Bruyère.

OUTLINE

• Background– Technology review– Evidence it works– Assistive technology framework

• Assistive Technologies Research Lab• Virtual reality in stroke rehabilitation• TAFETA

– Nocturia, nutrition, breathing, transfers

Aging Population vs. Services

• The number of older Canadian adults (65+) is projected to increase from 4.2 million to 9.8 million between 2005 and 2036.

• Between 2005 and 2020, the ratio of older Canadians to the labour force (15-64 years) is expected to rise from 25% in 2005 to 52% in 2020

• Aging in Place strategy• Canada will be short +/- 60K FTE RNs by 2022

Communication Tech Changes

Merchandise Tech Changes

Healthcare Tech Changes?

Evidence

OTN Telehomecare pilot program launched in March 2007

• provides care and monitoring to patients with– congestive heart failure (CHF)– chronic obstructive pulmonary disease

(COPD)

• over 800 patients enrolled

• largest Telehomecare program in Canada

Evaluation of Telehomecare Program

• Evaluated by PriceWaterhouseCoopers through survey tools

• Showed reduction of– 65% (avg #) of hospital admissions– 72% (avg #) of ER visits– 95% (avg #) of walk-in clinic visits

Ontario Telemedicine Network 2009 Annual Report

Gerontechnology FrameworkLIFE DOMAIN

GOALHealthSelf-esteem

Housing Daily living

MobilityTransport

CommunicationGovernance

WorkLeisure

EnrichmentSatisfaction

- self care- software personalisation

- interactive controls- teleservices- eShopping- adaptive control

- eBicycles- navigation tools- Info public transport

- mobile phone- e-mail- e-info- multimedia- e-learning- touch screens- mouse

- digital camera- tele-games- social computing- cash dispensers- tele-banking- DVD

PreventionEngagement

- healthy diet- hip protectors- health monitoring- eHealth info

- smart ventilation- safety illumination

- car automation - noise abatement- automated messages

- work simulator

CompensationAssistance

- passive alarms- medication reminders- tele-rehab- Viagra

- cleaning robots - scoot-mobile- smart walker- navigation tools

- accommodative lens implants- cochlear implants- retinal implants- delayed speech

- garden robots- robot pets

Care support& organisation

- control PDA- carer training system- clinical GT

- electronic keys - navigation tools - video links - telecare

At Bruyère Continuing Care, technologies are being researched that address important issues for our patients, such as, computer access, continence management, effectiveness of mobility aids, falls risk assessment, home safety monitoring, recovery following stroke, and support to caregivers.

Technology Related Research @ Bruyère

Continuing CareAssistive Technologies Research Lab

Dr. Jeff JutaiScientist, Bruyère Research Institute,

Professor, Faculty of Health Sciences, University of Ottawa

Current Projects

1. Nouse (nose-as-mouse): Pilot study with stroke patients (funded by BAMO)

2. Assistive Technology Outcomes Profile for Mobility (ATOP/M) (funded by National Institute on Disability and Rehabilitation Research)

3. Psychosocial impact of technologies for continence management (C-PIADS project) (funded by CIHR)

4. A multi-site randomized control trial of the impact of assistive technology with individuals with mobility limitations and their caregivers (CATS project) (funded by CIHR)

Nouse Project

PI: Hillel FinestoneCo-I: Jeff JutaiCo-I: Hilary McKeeCo-I: Melanie CarterCo-I: Jodie TaylorProject Co-ordinator:

Jasmine Mah

The unique, patented technology uses advanced video recognition algorithms to map the movement of the user’s nose to the movement of a computer mouse device thereby allowing a user to operate a computer hands-free.

Essentially, Nouse™ is recognized as the first technology to use the nose as the principal feature for facial tracking, a process that involves setting up a webcam on a computer equipped with tracking software.

The computer registers an image of your nose and then maps it onto the on-screen cursor, which you control with the movement of your nose. It enables the computer to track movements with dramatically improved precision over traditional methods.

Nouse™ application was developed for anybody to use, however, it will be most useful for those computer users who have difficulty using their hands to manipulate a mouse or keyboard, or for those who want to take breaks from using their hands due to fatigue/injury.

See a demonstration video of the Nouse at:

http://www.nouse.ca/Shop/

Nouse Project (cont’d)

ATOP/M Project

PI: Jeff JutaiCo-Is: Louise Demers (U.

de Montreal), Frank DeRuyter (Duke U.), Marcus Fuhrer (NIH), Jim Lenker (SUNY Buffalo)

Aim: To investigate user acceptability and clinical efficiency of the ATOP/M

The Assistive Technology Outcomes Profile for Mobility (ATOP/M) consists of 68 items distributed across two domains, each having two subdomains:

Activities (Physical Performance and Instrumental Activities of Daily Living);

Participation (Social Role Performance and Discretionary Social Participation).

ATOP/M yields two scores, one reflecting respondents’ mobility level while using a device, the other reflecting their capability without it.

The ATOP/M has been translated into Canadian-French, and a computer adaptive testing (CAT) has been developed.

ATOP/M Project (cont’d)

The following are example items.

ActivitiesPhysical Performance: Are you able to get around your

neighborhood or town?Instrumental Activities of Daily Living: Are you able to do yard

work like raking leaves, weeding, or pushing a lawn mower?

ParticipationDiscretionary Social Participation: Are you able to participate

in active recreational activities?Social Role Performance: Are you able to go to classes or

participate in learning activities?

For the following questions, please use the scale below:5=Without any difficulty; 4=With a little difficulty; 3=With some difficulty; 2=With much difficulty; 1=Unable to do

ATOP/M - Questionnaire

ATOP - Results

Results to date: Elderly mobility device users were able to

complete the computerized (CAT) version of the ATOP/M within 30 minutes. On average, only 12 items were required to obtain a reliable estimate for each of the with-device and without-device assessments.

C-PIADS Project

Aim: To measure the impact of continence technologies on the quality of life of elderly individuals

Interviews were conducted with elderly individuals who have continence problems and their caregivers.

– To identify important areas for impact of continence technologies and what modifications and enhancements might be needed to a self-report questionnaire called the PIADS

What kinds of products are you currently using for bladder and bowel control management? Please describe all of the different types of products you use.

What kinds of things do you do to help your bladder and bowel control management? Please describe all of the different things that you do.

In a typical day, what kinds of bladder and bowel control difficulties do you have?

What things are you able to do with your product(s) that you could not do without it/them? Are you able to do these things by yourself or do you need someone’s help?

What impact has your technology had on other people in your life (e.g., family, friends, caregivers, etc.)?

What do you like best about your current products and strategies? What positive effects do they have on your life?

What do you like least about them? What negative effects do they have on your life?

How satisfied are you with your current products and strategies?Take a few moments to think about the technology you want and need

most for managing your continence difficulties. Are there any barriers you face when trying to get and use it? Please describe.

C-PIADS - Interview Questions

C-PIADS Project

The participants were then asked to look at the Psychosocial Impact of Assistive Devices Scale (PIADS) and say whether they thought it was missing any item that may be important for continence.

C-PIADS - Results to Date

The PIADS seems to address most of the important psychosocial concerns of adults who have continence difficulties.

The development of a modified version for continence (C-PIADS) will require some modifications to the instructions and the addition of some new items which address stigma.

CATS ProjectPIs: Louise Demers (U. de

Montreal), Jeff Jutai (BRI), Frank DeRuyter (Duke U.), Ben Mortenson (Simon Fraser U.), Andrew Sixsmith (Simon Fraser U.)

Ottawa Site Co-ordinator: Emily CormierIn partnership with the Champlain

District Community Care Access Centre.

Aim: To investigate an intervention that involves a detailed in-home assessment of the person's current assistive technology and the negotiation and implementation of a personal assistive technology plan with the person and his/her caregiver.

CATS Project - Objectives

1) To determine the efficacy of this intervention for individuals with mobility limitations and for their caregivers.

2) To explore how the intervention is experienced by these individuals.

We anticipate this intervention will 1)increase the mobility, well-being, and

satisfaction with caregiver assistance of the individuals with mobility limitations;

2)reduce the amount of caregiver assistance required; and

3)decrease the psychological demands on caregivers and increase their satisfaction with caregiving-related activities.

CATS Project – General Hypotheses

This project is a multi-site research study. At each of the Montreal, Ottawa and Vancouver sites, we are enrolling 40 individuals with mobility limitations, and 40 of their caregivers (total of 120 dyads).

Eligibility criteria: client over 65 years of age, with a physical limitation, no evidence of cognitive deficit, and who lives with a caregiver that offers him/her at least 4 hours of care per week. Participants are assigned to either an immediate intervention group or to a delayed intervention group. Outcomes of this assistive technology treatment for individuals with mobility limitations and their caregivers are measured before and after intervention using a variety of standardized instruments.

CATS Project – Methods

The evidence produced by this study will enable service providers to offer assistive technology interventions that are more attuned to the needs of both individuals with mobility limitations and their caregivers and enable providers to lobby for better funding for equipment and follow-up intervention services.

CATS Project – Anticipated Impact

For further information:

Dr. Jeff Jutai jjutai@uottawa.ca

Research lab located at:Saint-Vincent Hospital, Annex B, 3rd floor

Lab phone (SVH): 613-562-6262 x2245

Technology Related Research @ Bruyère

Continuing Care

Virtual reality in stroke rehabilitation

Dr. Hillel FinestoneDirector of Stroke Rehabilitation Research, Bruyère Continuing Care

Associate Professor, Division of Physical Medicine and Rehabilitation, University of Ottawa

Research Team

Dr. Martin Bilodeau, PhD

Associate Professor and Director, School of Rehabilitation Sciences, University of OttawaCo-investigator

Dr. Heidi Sveistrup, PhD

Professor and Vice-Dean, Research and Graduate Studies Faculty of Health Sciences, University of OttawaCo-investigator

Dr. Hillel Finestone

Director, Stroke Rehabilitation ResearchElisabeth Bruyère Hospital, Bruyère Continuing CareAssociate Professor, University of OttawaPrimary Investigator

Research Team (cont’d)

Anne Taillon-Hobson

BSc (PT), MScResearch Associate, VRRASS

Dan McEwen

PhD candidate, School of Rehabilitation SciencesUniversity of Ottawa

Dr. Leo Tseng

Division of Physical Medicine and Rehabilitation University of Ottawa

Introduction• Balance impairments (Barclay-Goddard et al., 2004)

and independent walking (Patel et al., 2000) are frequently impaired in the post-stroke population

• Balance has been shown to improve following retraining (EBRSR – Evidence-Based Review of Stroke Rehabilitation, www.ebrsr.com, 2007)

• Virtual reality (VR) exercises have been shown to improve balance in the community-dwelling TBI population (Thornton et

al., 2005) and in adolescents with cerebral palsy (Brien & Sveistrup, 2011)

Introduction (cont’d)

• VR exercises transfer to real-world situations (Jaffe et al., 2004; Lam et al., 2006), potentially improving community-based functional activities such as walking in a risk-free environment (Lam et al., 2006)

• VR exercises can enhance family/community involvement in rehabilitation of patients (Thornton et al., 2005; Finestone, 2011)

Introduction (cont’d)

• Laver et al. (Cochrane Database, Sept. 2011) and Deutsch (2012) concluded that future studies investigating the use of VR exercises in rehabilitation should be characterized by:– robust methodologies, including blind

and randomized protocols– the inclusion of inpatient populations

VRRASS Project

• Objectives:1. Determine whether VR, as an adjunct

treatment, is beneficial for rehabilitation by improving balance and function in the inpatient stroke population

2. Establish whether VR exercises are safe and feasible to implement in an inpatient rehabilitation environment

3. Document stroke patient satisfaction with VR exercise programs

Virtual Reality Rehabilitation After Stroke Study

What is Virtual Reality (VR)?

“A simulation of a real world environment that is

generated through computer software and is experienced by the user

through a human–machine interface”

(Holden, 2005)

Methods

Treatment Group

• N = 30• Conventional

therapy + VR exercise while standing

Control Group

• N = 30• Conventional

therapy + VR exercise while sitting

Inclusion/Exclusion Criteria

Inclusion

1. Ability to stand independently for >1 minute

2. Ischemic or hemorrhagic stroke in left or right cortical or subcortical region

3. Balance and gait deficits resulting from stroke

4. Ability to understand and follow instructions

5. Ability to provide informed consent

Exclusion

1. Severe cognitive impairments or unable to follow instructions

2. Unstable medical condition

3. Vestibular deficits or vertigo

4. Seizure activity in past 6 months

Outcome Measures

• Berg Balance Scale and, if ≥ 48, Community Balance and Mobility Test

• Functional Independence Measure (FIM)• Chedoke-McMaster Stroke Assessment

(arm, leg, posture)• Two-Minute Walk Test• Timed Up & Go Test• Quasi-static measures (centre of pressure,

pressure mat)• Ottawa Sitting Scale

Randomization Patient admitted to Élisabeth Bruyère Hospital and assessed for medical suitability

Suitable for the Study?

YES NO

Routine care and therapies

Primary care nurse obtains verbal consent from patient to meet VRRASS research associate

Patient contacted by VRRASS research associate who details the study to the patient and provides written information

Patient consents to participate in the study?

Consent form signed and clinical outcome measures initiated

Routine care and therapies

YES

NO

Protocol

• Daily 30- to 45-minute sessions of which20–25 minutes are VR exercises

• 6–10 sessions• Outcomes assessed three times:

– Before training– Following the end of training– 1 month after the end of training

Statistical Analysis

• Baseline demographics• Repeated-measures analyses to determine

significant differences in outcome measures across the three test sessions

• SPSS 17.0 software, α level of 0.05

Preliminary Results

May 1, 2011–April 30, 2012

Stroke Unit Patient DemographicsN = 206

104 men, 102 womenMean age: 68 years (range 21–89)FIM mean total score: 75 (range 23–114)FIM mean motor score: 55 (range 17–90)FIM mean cognition score: 20 (range 6–33)

Eligible for study?

Yes49

No157

Eligible Participant Demographics

49 patients eligible for study

Enrolled: 38

20 men – mean age 60 (range 21–86)18 women – mean age 61 (range 26–88)FIM mean total score 93 (range 62–110)FIM mean motor score 69 (range 37–88)FIM mean cognitive score 24 (range 13–30)

Refusals/unsuitable: 11

Hate computers 2Too anxious to learn 1Not interested 7Not stroke 1

Continue with routine care and therapies

27 active participants

23 have completed 3/3 phases4 have completed 2/3 phases

10 withdrawals

Early discharge 2Too tired 2Fear of second stroke 1Increase in cluster headaches 1Noncompliant with protocol 2Technical problems 2

38 patients enrolled

Participant Demographics

1 lost to follow-up

Participant Demographic Features

FeatureTreatment group (n =

18)

Control group (n =

20)

Mean age (yr) 61 62

Sex Male 8 12

Female 10 8

Side of stroke Right 8 7

Left 9 11

Bilateral 1 2

Type of stroke Ischemic 15 19

Hemorrhagic 3 1

Location of stroke Cortical 14 16

Subcortical 8 13

No. of days between stroke and start of VR training

29 38

Lessons Learned So Far

• What % of newly admitted stroke rehabilitation inpatients can stand for >1 minute?

→ likely only 20%• Balance requirement may skew

age/disability level of subjects selected• Cognition influences participation• Scheduling is critical• Most participants find it enjoyable

Next…

• Finish recruitment• Analyse data• Submit results for publication• Apply for grant: “VR and the

Seated/Wheelchair Population”

Questions?

Thank you!

Role of Technology in Supporting

“Aging in Place”Dr. Frank Knoefel

Co-Lead, TAFETA project,

Clinical Scientist, Bruyère Research Institute

Technology Related Research @ Bruyère

Continuing Care

What is TAFETA?

Technology

Assisted

Friendly

Environment for the

Third

Age

Technologie

Avancée pour

Faciliter

l’Environnement du

Troisième

Age

TAFETA

• Multi-disciplinary team: clinicians and engineers

• Bruyère Research Institute, Bruyère Continuing Care, Carleton U, uOttawa…

• Change Foundation grant 2003 • Model apartment in 2004 • Over $1 M in grants from various agencies

CMHC Fridge

Fridge Use: Tri-modal

Fridge Use: Bi-modal

Fridge Use: Multi-modal

Pressure Sensitive Mat

NOCTURIA - RESULTS

Sit to Stand - Methodology

Sample sit-to-stand sequence imagesTiming – Bouncing - Symmetry

4

Hip

RH

Hip

LHRH

Hip

LHRH

LH

Hip pressure region 1

Hip

Hip and hand pressure regions

Hand pressure regions Bed Exit Position

1 2 3

Sit-to-stand Results - Healthy volunteer

0.5 1 1.5 2 2.5 30

0.2

0.4

0.6

0.8

1

Time (sec)

Nor

mal

ize

d P

ress

ure

HipLHRH

0 1 2 3 4 5 6 70

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1P1269 Older Stroke-3

Time (sec)

Nor

mal

ize

d P

ress

ure

- 1

=17

429

Bed PressureShuffle

0 1 2 3 4 5 6 7 8 90

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1P1269 Older Stroke-2

Time (sec)

Nor

mal

ize

d P

ress

ure

- 1

=18

109

Bed PressureBounce

0 1 2 3 4 50

0.2

0.4

0.6

0.8

1

Time (sec)

Nor

mal

ize

d P

ress

ure

- 1

=15

110

Bed PressureUnsuccessful Transfer

1. Shuffling in the sit position

2. “Bouncing” to generatemomentum before

standing up

3. Unsuccessful transfer

Sit-to-stand Transfer - Older Adults

Mat Intelligence

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 50

1

2

3

4

5

6

7

8

9

group

tim

e (

s)

1=Young Healthy, 2=Older Healthy, 3=Stroke, 4=Hip

YH OH

OS

OHip

MOBILITY - Individual over time

Centre of Pressure Study

• For each transfer, the sagittal CP was observed over time and its deviation was measured

y y y y

x

Centre of Pressure - Results

Healthy Mobility-impaired

Difference

Sagittal Deviation

0.48 ± 0.23 1.56 ± 0.51 p < 0.001

BREATHING - Results

BREATHING - Results II

Acknowledgements

• Dr. Rafik Goubran, Dean Engineering, Carleton University, co-lead TAFETA

• Drs. Martin Bilodeau, Jeff Jutai, Heidi Sveistrup

• Stéfanie Rocan, Project Manager• Numerous learners: Health and Engineering

• CIHR, NSERC, CMHC, Sens Foundation

Questions?