Challenges for Adopting Virtual Rehabilitation

Report

Virtual Rehabilitation for Children: Challenges for Clinical Adoption

Glegg S

IEEE Pulse, November 16, 2017

DOI: 10.1109/MPUL.2017.2750838

Link to abstract: http://ieeexplore.ieee.org/document/8110871/

Virtual rehabilitation… “allows clinician to control the characteristics of the virtual environment while modifying the degree of challenge to suit individual patient needs”. A recent cross-Canada survey found challenges like "lack of time, funding, treatment space, appropriate patients, and support staff", along with low therapist self-efficacy. However, also reported are facilitating factors such as the capabilities of the software to accommodate patients with differing skills and availability of an evidence base to support use among other factors. Additionally, games are typically made for an older cohort than the children in pediatric rehabilitation, and that parents may want to limit children’s screen time.

"… Implementation of virtual rehabilitation technology requires support for clinicians as they learn how to optimize applications to benefit these patients."

Cell Phones Rehab Games!

Paired Groups

Motor performance of individuals with cerebral palsy in a virtual game using a mobile phone

de Paula JN, de Mello Monteiro CB, da Silva TD, Capelini CM, de Menezes LDC, Massetti T, Tonks J, Watson S & Nicolai Ré AH

Disabil Rehabil Assist Technol. 2017 Nov 1:1-5.

doi: 10.1080/17483107.2017.1392620. [Epub ahead of print]

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/29092683

This seems a great combination for children with cerebral palsy: Game play encouraged on cell phones for motor improvement.

What? For children with cerebral palsy, does game play on a mobile phone result in motor improvement compared to a control group?

How? Participants with cerebral palsy (GMFCS level I and MACS level I) played 25 repetitions of a maze game on cell phones. They were sex- and age-matched with normally developing children. Then they were introduced to a new maze task for 5 trials.

Findings: "We found a significant improvement in the movement time between the first (trial) attempt relative to the last (trial) attempt for the individuals with CP". They did not retain this speed improvement in the new maze task.

We can all play together

Repeated Measures

Ability-based Balancing using the GMFM in Exergaming for Youth with Cerebral Palsy

MacIntosh A, Switzer L, Hwang S, Schneider A L J, Clarke D, Graham T C N & Fehlings D

Games for Health Journal 6 (6), 2017

DOI: 10.1089/g4h.2017.0053

Link to abstract ncbi.nlm.nih.gov/pubmed/29016199

What? Among differently-abled players with cerebral palsy, can "GMFM Ability-based balancing" result in enjoyable fair play for all?

How? Eight 8-14 year olds with GMFM ability level II and III scores played video games in dyads using three different algorithms to even game play.Each dyad went head-to-head three times, using one of three algorithms to balance the competition between them. The three algorithms were a GMFM ability balance, an idealized balance and a control algorithm. The players were asked if the gameplay was fun and fair.

Findings: GMFM Ability-based balancing resulted in the best fit of play that was both ability-balanced and enjoyable.

The Wizard behind the Robot

Case Reports

Wizard of Oz studies with Children

Hoysniemi J & Read J

Link to article: citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.124.4282&rep=rep1&type=pdf

What? This article reports on case studies about Wizard of Oz robots and children. ‘Wizard of Oz’ refers to the human behind the curtain who animates robot’s interaction with children. The robot is not autonomous but operated to some greater or lesser degree by a human wizard, as close to real time as possible.

Why? Wizard of Oz studies are interested in modelling and examining characteristics of computer-human interactions and the capabilities and limitations of autonomy in robots. These studies allow researchers to efficiently try out ways of interacting that might become programmed behavior in a more autonomous robot. It allows collection of data.

What was found? What is the balance between robot autonomy and the wizard in responses to the participant, and the delay inherent in this. Delays that occur as the wizard prepares a response for the robot to make were recognized as a limitation. Of mention is the notion of deception: whether or not the wizard being hidden or seen was an issue for children. Children mis-attributed autonomy to the present wizard even when there were keyboarding sounds occurring at the same time as the wizard was responding. Is there a responsibility on researchers regarding consent when children don’t understand there is a human behind the robot?

My (robot) friend

Blog post

Making new robot friends: Understanding children’s relationships with social robots

Westlund JMK

Published in mit media lab: Personal Robots Group blog, June 13, 2017

Link to blog: media.mit.edu/posts/making-new-robot-friends/

"Hi, my name is Mox! This story begins in 2013, in a preschool in Boston, where I hide, with laptop, headphones, and microphone, in a little kitchenette. Ethernet cables trail across the hall to the classroom, where 17 children eagerly await their turn to talk to a small fluffy robot."

In this engaging blogpost, the author describes a robot used to explore the nature of relationships children build this social, teleoperated machine. In playtests with children, the author learns they form an understanding of robots that differ from the relationship with the robot’s human operator; from pets, from inanimate possessions and from people. Adult ontologies are not applied by children: person or machine, real or imaginary; no condition excludes the possibility of a friend. Characteristics like expressiveness and responsiveness are found to contribute to connection and learning. Robots can ask questions that encourage the child to greater engagement in a story and cue parents to ask similar questions.

Finally, the author expresses concerns about the ethics of providing engaged machines to children and issues a call to engagement in ‘roboethics’.

Research proposal: Transparency, Teleoperation, and Children’s Understanding of Social Robots, Westlund JMK & Breazeal C

Link to research proposal ieeexplore.ieee.org/document/7451888/

Therapists across Canada Surveyed on VR and Active Video Games

Survey

Virtual Reality and Active Videogame-Based Practice, Learning Needs, and Preferences: A Cross-Canada Survey of Physical Therapists and Occupational Therapists

Levac D, Glegg S, Colquhoun H, Miller P & Noubary F

Games for Health Jorunal Volume 6, Number 4; 2017

DOI:10.1089/g4h.2016.0089

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/28816511

Objective: To conduct a cross-Canada survey to poll therapists on virtual reality and active videogame (VR/AVG) use.

Process: A convenience sample of 1071 therapists was polled online using the ADOPT- VR2 instrument (Assessing the Determinants of Prospective Take-up of Virtual Reality).

Findings: Almost half of the respondents had experience with VR/AVG. Factors that favoured VR/AVG use include the technology’s perceived usefulness and the therapists’ sense of self-efficacy.

Barriers to use include “lack of funds, space, time, support staff and appropriate clients”, and “facilitators included client motivation, therapist knowledge and administrative support”. Most of the respondents indicated an interest in learning more about VR/AVG treatment-based programs.

Robot rules and features

Survey

Designing a Robot Companion for Children with Neuro-Developmental Disorders

Gelsomini M, Degiorgi M, Garzotto F, Leonardi G, Penati S, Ramuzat N, Silvestri J & Casadonte F

IDC '17 Proceedings of the 2017 Conference on Interaction Design and Children 451-457

DOI>10.1145/3078072.3084308

Link through to full text: //dl.acm.org/citation.cfm?id=3084308

Objective: The authors set out to do two things.

1. to collect information from 15 pediatric therapy ‘specialists’ and create a list of desired properties in a robot companion
2. to study the classes of features that are present in available robots

Process: 21 common robots are chosen, and the concepts are both outlaid in matrixes for comparison.

Findings: The authors come up with “Robot’s Rules”. First, desired properties: a therapy robot should facilitate, prompt, restrict, emulate, provide feedback; and act as a social mediator, an affective agent and an emotional agent. Secondly, the five classes of features that social robots should have are identified: appearance, multimodality, multisensorialilty, configurability and safety.

Test of Playfulness with CP Kids

Single group

Playfulness in Children with Limited Motor Abilities when using a Robot

Rios AM, Adams K, Magill-Evans J, & Cook A

Physical & Occupational Therapy in Pediatrics (IPOP)

DOI: 10.3109/01942638.2015.1076559

Link to full text:https://era.library.ualberta.ca/files/8g84mq002/Rios%202016%20IPOP.pdf

Objective: For children with limited motor skills, how does robot play change playfulness?

Process: Four children with GMFCS levels IV or V played with Lego robot for 15 minutes twice a week for 14 weeks. The Test of Playfulness was applied at baseline, during intervention and at follow-up.

Findings: "Test of Playfulness scores of the four children with cerebral palsy significantly increased during the intervention compared with baseline."

Sensorimotor Robot Therapy: the Anklebot

Pilot study

Pediatric robotic rehabilitation: Current knowledge and future trends in treating children with sensorimotor impairments

Michmizos KP & Krebs HI

Neurorehabilitation (pre-press) DOI: 10.3233/NRE-171458

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/28505989

Objective: "As long as motor learning remains the major working hypothesis for sensorimotor rehabilitation, a well-designed robotic therapy… should follow the principles of motor learning, namely massed practice, cognitive engagement and functional relevance." Sensorimotor therapy is identified as three elements: discrete and rhythmic movements, and interaction with the environment.

Process: The application of the Pedi-Anklebot 'robot' is to target ankle movements and functional walking for children with motor disabilities. The authors use the games designed to treat reduced speed, strength, accuracy, co-ordination; and cognitive or perceptual difficulties. To provide comprehensive sensorimotor therapy, practice included discrete sub movements, rhythmic oscillations and practice with ground contact.

Conclusion: "To fully harness the therapeutic power of adaptation, we need to continue our research on the special characteristics of [the] sensorimotor control… on the differences between rhythmic and discrete movements, as well as mechanical impedance training."

Robots Learn to Play

Review

Robots Learn to Play: Robots Emerging Role in Pediatric Therapy

Howard AM

Proceedings of the 26th International Florida Artificial Intelligence Research Society Conference, 2013

Link to full text: www.aaai.org/ocs/index.php/FLAIRS/FLAIRS13/paper/view/5838/6033

Objective: Therapy for children includes play; at best, robots will express this quality as they are brought into the pediatric setting. Three types of robots are discussed in this article: robots (smart toys) that are operated by alternative inputs such as the smart phone, robotic orthoses that include an element of play, and autonomous robots that interact through play. In each case, examples are given.

Discussion:

1. ‘Robot’ or smart toys are considered here as toys which children can play with using an alternative means of manipulation. True smart toys possess some awareness of their surroundings and additionally require some degree of autonomy to meet the definition of robot.
2. Robotic orthoses or exoskeletons guide, limit and assist in motor movements of upper and lower extremities. Play can be incorporated into this therapy.
3. Autonomous robot toys which engage children with intentional, purposeful imitation play. "While typically developing children possess the ability to imitate others from birth, children with pervasive developmental disorders, such as autism, demonstrate significant difficulty in object and motor imitation. Imitation skills are thought to be closely related to early language and social abilities."

Conclusion:"It seems natural then that this research thread (autonomous robotic playmates capable of engaging children in shared manipulation-based play), along with … quantitative results… emerges as the next step in the domain of robots for pediatric therapy."

Balanced Games = More Fun

Pairs study

How Game Balancing Affects Play: Player Adaptation in an Exergame for Children with Cerebral Palsy

Hwang S, Schneider ALJ, Clarke D, MacIntosh A, Switzer L, Fehlings D & Graham TCN

Conference proceedings: ACM DIS 2017, June 10 – 14, 2017, Edinburgh UK

Link to abstract: dx.doi.org/10.1145/3064663.3064664"

Player balancing changes game mechanics to accommodate differences in players’ manual and cognitive abilities. Addressing the imbalances also involves players’ awareness of a new fairness that may motivate both the advantaged and disadvantaged players.

Objective : When children with CP play knowingly balanced exergames, do the effects (including motivation) persist?

Process : Eight participants 8 – 14 years old with GMFCS scores of II or III experienced 6 hour-long sessions of either balanced or unbalanced game play.

Findings : "Our results showed that motivation was higher in balanced versus non-balanced conditions [and] perceived fun and fairness were higher for both winners and losers in balanced versus non-balanced conditions."

Testing a Therapy Assistant Robot

Proof of Concept

Adapting a General Purpose Robot for Paediatric Rehabilitation: In-situ Design of a Socially Assistive Robot

Carrillo FM, Butchart J, Knight S, Scheinberg A, Wise L, Sterling L & McCarthy C

Link to article:https://arxiv.org/abs/1705.05142

Objective: Socially Assistive Robots are engaging and motivating. For social robots in pediatric rehabilitation, what are the therapist, carer and patient-centric properties needed for robots to be effective stand-alone therapeutic aids? What are the lessons from ongoing use in a clinical setting?

Process: Development began with weekly visits to clinic with the robot to stimulate brief discussions with parents and therapists; and interactions with children, followed by programmers involving therapists in cycles of programming the NAO robot and reviewing the exercise sequences. Later development shifted the sole operation of the robot to therapists, parents and care-givers. Clinical use of the robot had 5 therapists working with 9 patients over 14 sessions and continued the iterative design process.

Outcomes: The authors state: “this (deployment) approach has led to a system that not only meets minimum operational and therapeutic requirements for clinical deployment, but also has clearly established priorities for further development as we prepare for formal clinical trials of the socially assistive robot for pediatric rehabilitation.”

Distance Rehab for Kids – A Case Report

Case Report

Feasibility of Pediatric Game-Based Neurorehabilitation Using Telehealth Technologies: A Case Report

Reifenberg G, Gabrosek G, Tanner K, Harpster K Proffitt R & Persch A

American Journal of Occupational Therapy, 71 7103190040

DOI: doi.org/10.5014/ajot.2017.024976

Objective: Feasibility of and suitable outcome measures for distance-monitored video game rehabilitation.

Process: A child with hemiparetic spastic cerebral palsy played 7 hours weekly for 8 weeks of computer games monitored at a distance by a therapist via videoconference technology KUBI The setup permitted the remote therapist to move their camera (iPad) to see the child and the child’s position. The distance therapist consulted with child and parents 30 minutes each week for technical issues.

The outcome measures that were expected to detect change before and after the test condition were: Quality of Upper Extremity Skills Test (QUEST), Bruininks-Oseretsky Test of Motor Proficiency 2 Ed.(BOT-2), Assisting Hand Assessment (AHA), Pediatric Evaluation and Disability Inventory-Computer Adapted Test (PEDI-CAT) and Pediatric Motor Activity Log (PMAL). Pre- and post- tests were applied two weeks before and after the game sessions.

Findings: Feasibility – the audio quality was sufficient for the therapist to interact with the child and family, and the video quality allowed the therapist to see the child’s activity without seeing the TV monitor. There were no insurmountable technical issues though this subject and family were familiar with the technologies used and so this case did not represent a truly novel situation.

Measures – All the measures were sensitive to change in the child’s performance before and after the test condition except the QUEST.

“The use of telehealth technologies provides practitioners with a mechanism to supervise treatments for clients in underserved communities. This research provides initial evidence that it is feasible to administer game-based neurorehabilitation and telehealth technologies and monitor relevant outcomes.”

Wearable Tech for Rehabilitation: Interactive Wearable Systems

Survey

Interactive Wearable Systems for Upper Body Rehabilitation: a Systematic Review

Wang Q, Markopoulos P, Yu B, Chen W & Timmermans A

Journal of Neuroengineering and Rehabilitation (2017) 14:20

DOI 10.1186/s12984-017-0229-y

Note: this paper performs a survey of the literature; the authors do not report the outcome of the PRISMA protocol.

Interactive wearable systems (IWS) measure range of motion, posture or usage; and provide auditory, visual or tactile feedback. Posture monitoring is traditionally performed by a therapist. When devices can provide accurate and reliable feedback, IWS opens up the possibility of independent training.

Objectives: A) to classify interactive wearable systems used for movement and posture monitoring during upper body rehabilitation, B) to gauge the wear-ability of the systems and C) to perform a literature review.

Process: A) The authors created a matrix of three axes to classify IWS technology.The axes reflect

• sensor technology – how it measures: (accelerometers or inertial measurement units, angular sensors or other);
• measurement - what is measured: (body posture, range of movement or amount of use); and
• the way feedback is delivered: (auditory, visual, tactile or multi-modal).

B) Wear-ability is classified by the following criteria: the sensor system should remain in place on the body, be comfortable, flexible enough not to limit movement, easy to use and fit different body shapes.

C) The authors included 45 papers, classified by the literature by the level of involvement with patients and the level of evaluation as technical, regarding usability, or clinical. The largest group of papers report on usability evaluation on normal subjects or with ‘real patients’ in stroke rehabilitation. Three papers report clinical evaluation with clinical patients, and one randomized controlled trial was found in the literature. Since a similar review in 2008, there have been only small improvements in the strength of clinical evidence for interactive wearable systems.

Findings: The strength of this paper is in the creation of a matrix for classifying interactive wearable devices. The authors also propose (but do not employ) a list for evaluating the wear-ability of such systems. This report provides a systematic way of regarding interactive wearable systems.

Exergame for CP Kids: GMFCS III Shuttle Run Test

Pilot study

An innovative cycling exergame to promote cardiovascular fitness in youth with cerebral palsy

Knights S, Graham N, Switzer L, Hernandez H, Ye Z, Findlay B, Xie W Y, Wright V & Fehlings D

Developmental Neurorehabilitation 2016 19(2): 135-140
DOI: 10.3109/17518423.2014.923056

Link to abstract

Objective: For youth with cerebral palsy, will playing an exergame increase cardiovascular fitness?

Procedure: The participants were 8 children with spastic bilateral cerebral palsy (GMFCS level III), able to use a hand-held video controller to play an internet-based multi-player game over a six week trial. They exercised at home at least three days a week for 30 minutes a day and tasked to achieve their individually calculated target heart rate for at least 30 minutes a week.

Findings: The primary measure was the GMFCS level III-specific shuttle run test; where higher levels indicate higher cardiovascular fitness. Participants walk or run a distance of 7.5 meters with increasingly less time until they fail to make the distance in the time given, twice. The children were tested before and two days after the six week intervention. The results showed a significant improvement of an average of 1.7 levels on the shuttle run test. Other outcome measures did not show changes that were significant.

Reference: Reliability of a shuttle run test for children with cerebral palsy who are classified at Gross Motor Function Classification System level III

Social Robots: NAOTherapist

Proof of Concept

NAOTherapist: Autonomous Assistance of Physical Rehabilitation Therapies with a Social Humanoid Robot

Pulido J C, Gonzalez J C & Fernandez F

Proceedings of IWART 2016: International Workshop on Assistive and Rehabilitation Technologies, Elche, Spain, December 14 – 16, 2016

Link to paper

Link to video

Objective: The goal of this work is to identify the architecture needed for NAO to provide therapy without human supervision.

Discussion: Social robots may act to relieve the workload of the therapist, fulfilling the clinical objectives autonomously over many treatment sessions. In this study, early requirements of a robotic therapist have been previously identified: the children had no problem following the instructions; they enjoyed the activity and adhered to the regimen.

For autonomous therapy, the robot must possess social awareness in addition to offering exercises that it models, monitors, encourages and corrects. It should be able to report back results to the therapist. In this case, NAO is doing successive arm poses with the child. The robot greets the child. It then models each arm pose, checks on the position achieved by the child, encourages and corrects the pose by using a variety of strategies to model the pose and to show how move into that pose. NAO times the correct achievement of the pose. Here, Kinect is being used separately to capture the poses for feedback to the therapist. NAO indicates the completion of each pose and the exercise routine and offers a wish to "play again tomorrow".

Robot assists with kids mobility

News

Interactive robot to promote rehabilitation for children with special needs

Kukich D. Published in UDaily, Communications and Public Affairs, University of Delaware, Jan 11, 2016

Link to story

At the University of Delaware in Newark, a research team including mobility researcher Cole Galloway are using "NAO", an interactive human-like robot in a new approach to pediatric rehabilitation. Dr. Galloway, who is known for his Pediatric Mobility Studio and GoBabyGo program, is incorporating the robot into his lab research. His research is directed by the concern that children with motor disabilities have needs that are not met by the training and equipment available today. "Young children’s overall knowledge depends on their ability to be mobile with peers — once they start moving, they begin to learn about the world in fundamentally different ways." The intention of including NAO in the mobility environment is to have the children engage with the robot, and for the robot to facilitate training.

Links

Update on Dr. Galloway's activities

Pediatric Mobility Lab and Design Studio

GoBabyGo "All people exploring their world via independent mobility!"

NAO robot - Softbank Robotics.com

Gait Robots Help Upper Body Posture

Randomized Controlled Trial

Robotic-assisted gait training improves walking abilities in diplegic children with cerebral palsy

Wallard l, Dietrich G, Kerlirzin Y & Bredin J

European Journal of Paediatric Neurology 2017, http://dx.doi.org/10.1016/j.ejpn.2017.01.012

Link to abstract

Objective: For children with diplegic cerebral palsy, robotic-assisted gait training (RAGT) can result in improved gait and posture compared to children who receive only traditional physical therapy. Of particular interest here is dynamic equilibrium control: upper body strategies such as shoulder elevation and elbow flexion used to maintain balance while propelling forward.

The authors propose: "RAGT presents beneficial effects on improvement of postural and locomotor functions of the patient resulting in a reorganization of gait pattern and full-body kinematic illustrating the dynamic equilibrium control in gait. This would translate in a better stabilization of the head, a better control of the displacement of the arms associated with an improvement in the kinematics of the lower limb."

Process: Thirty children with diplegic cerebral palsy from 8 to 18 years of age were randomly assigned to either a treatment group or a control group. The treatment group received 40-minute sessions of Lokomat Pediatric robot-assisted walking therapy, 5 days a week for 4 weeks. Body-weight support and walking speed were altered through the sessions to match the child’s functional capacity. The control group received daily 40-minute sessions of traditional therapy.

Findings: Gross Motor Function Classification System dimensions GMFM- D (standing) and GMFM-E (walking/running/climbing) were measured and showed improvement within the treatment group, and between treatment and control groups.

Children in the treatment group demonstrated new strategies for gait with significantly reduced shoulder elevation and elbow flexion, "more appropriate control of the upper body... associated with an improvement of the lower limbs kinematics which is similar to the values observed in typically developing children."

There was no follow-up to indicate whether the effects are preserved over the long term.

Robot Gait Rehab: Systematic Review

The effectiveness of robotic-assisted gait training for paediatric gait disorders: systematic review

Lefmann S, Russo R & Hillier S

Journal of NeuroEngineering and Rehabilitation 201714:1

DOI: 10.1186/s12984-016-0214-x

Link to full text: jneuroengrehab.biomedcentral.com/articles/10.1186/s12984-016-0214-x

Objective: to review evidence for robotic-assisted gait training (RAGT) in children and adolescents with gait disorders as a consequence of cerebral palsy; or of musculo-skeletal, neurological orthopedic origin.

Process: Six databases were searched from 1980 to October, 2016. Data were extracted using the PRISMA model. http://www.prisma-statement.org/

Outcomes: Three trials that met the standard of randomized controlled trial; two were selected. Meta-analysis of the two trials showed "weak and inconsistent evidence regarding the use of RAGT for children with gait disorders".

Studies of lower design related mostly to children with cerebral palsy; these did show improved gait attributes such as speed, standing ability and walking distance. "… a clinical recommendation to adopt RAGT in children and adolescents with gait impairment cannot be made until more consistent findings are reported in larger randomized controlled trials."

Therapy Designers and Game Designers: We Should Get Together

Perspective

Gamification in Physical Therapy: More Than Using Games

Janssen J, Vershuren O, Renger WJ, Ermers J, Ketelaar M & van Ee, R

Pediatric Physical Therapy 2017;29:95-99

Link to abstract: www.ncbi.nlm.nih.gov/pubmed/27984481

Objective: “By reducing the gap between therapy designers (therapists) and game designers, there is a huge potential to gain more from the potential value of participant-specific games.”To apply the attractiveness, motivation and engagement of video games to therapeutic goals, the authors propose three pathways: adding game principles to therapy (gamification), adding therapeutic tools to commercial games and selecting applied games suited to the therapeutic needs of the child.

Discussion: There are parallels between game design and therapy design. A process for bringing together game designers and therapy designers to optimize therapy is proposed.