Activities and Evaluations for Technology-Based Upper Extremity Rehabilitation

Recent advances in projection and sensing have resulted in an increased adoption of virtual reality, video games, and interactive interfaces to improve patient compliance with rehabilitation programs. In this chapter, we describe the application of multi-touch tabletop surfaces to physical and occupational rehabilitation programs that are focused on the upper extremities. First, we detail the participatory design processes undertaken with local physical and occupational therapists to design and integrate a ‘patient-friendly' multi-touch tabletop system in their workplace. We then explore the design considerations that informed the development of a suite of sixteen multi-touch interactive activities. The design considerations highlighted the need for customization and flexibility in the software, as well as the importance of supporting a variety of activity types. We then detail the laboratory-based methods that were used to evaluate the efficacy of the activity interventions as well as our deployment of the system in a local rehabilitation hospital. Our evaluation, which employed both qualitative and quantitative components (i.e., the Intrinsic Motivation Inventory, semi-structured interviews, kinetics and kinematics recorded from motion trackers and an electromyogram recorder), determined that it is the design of activities, rather than the utilization of technology itself, that impacts the success of technology-assisted rehabilitation. The chapter concludes with a discussion of the implications of our system and its deployment.

Adaptation and Customization in Virtual Rehabilitation

Background. Adaptation and customization are two related but distinct concepts that are central to virtual rehabilitation if this motor therapy modality is to succeed in alleviating the demand for expert supervision. These two elements of the therapy are required to exploit the flexibility of virtual environments to enhance motor training and boost therapy outcome. Aim. The chapter provides a non-systematic overview of the state of the art regarding the evolving manipulation of virtual rehabilitation environments to optimize therapy outcome manifested through customization and adaptation mechanisms. Methods. Both concepts will be defined, aspects guiding their implementation reviewed, and available literature suggesting different solutions discussed. We present “Gesture Therapy”, a platform realizing our contributions to the field and we present results of the adaptation techniques integrated into it. Less explored additional dimensions such as liability and privacy issues affecting their implementation are briefly discussed. Results. Solutions to implement decision-making on how to manipulate the environment are varied. They range from predefined system configurations to sophisticated artificial intelligence (AI) models. Challenge maintenance and feedback personalization is the most common driving force for their incorporation to virtual rehabilitation platforms. Conclusions. Customization and adaptation are the main mechanisms responsible for the full exploitation of the potential of virtual rehabilitation environments, and the potential benefits are worth pursuing. Despite encouraging evidence of the many solutions proposed thus far in literature, none has yet proven to substantially alter the therapy outcome. In consequence, research is still on going to equip virtual rehabilitation solutions with efficacious tailoring elements.

The Use of Virtual Reality Tools for the Assessment of Executive Functions and Unilateral Spatial Neglect

Virtual Reality is one of the most promising tools in the development of new methods for neuropsychological assessment and rehabilitation. Neuropsychological assessment is typically carried out by administering paper-and-pencil tests to patients. However, these tests have some limitations, due to the fact that they are not effectively able to evaluate the subject's performance of daily activities. To cope with this void, neuropsychologists base their evaluation on their clinical experience, often successfully. Nevertheless, this is not an evidence-based practice, thus it is not considered optimal from a medical decision-making perspective. More recently, however, the increasing accessibility of advanced technology such as virtual reality has opened new possibilities for neuropsychological assessment and rehabilitation. Starting with this frame, the chapter explores the changes that have occurred over time in the neuropsychological assessment and rehabilitation up to the most recent VR-based tools. In particular, we will present a VR-based PC tool for the assessment of executive functions, and a VR-based mobile tool for the assessment and rehabilitation of unilateral spatial neglect. In accordance with the literature, we show the potential for virtual reality, highlighting the advantages, limitations, and the possible future challenges.

A PhysX-Based Framework to Develop Rehabilitation Systems Using Haptics and Virtual Reality

The use of Virtual Reality (VR), in combination with haptic devices (i.e. robotic manipulators capable of generating forces that stimulate the tactile and/or proprioceptive system of the users) is becoming very popular in the field of rehabilitation. As matter of fact, different rehabilitation requirements, related to various pathologies, are usually addressed by developing specialized haptic devices, together with specific VR worlds and exercises to be performed within. This, in turn, usually brings a tremendous effort when new exercises must be designed and/or new haptic devices, with their mechanical model and hardware (HW) interfaces, must be embedded into an existing environment. To cope with the required flexibility and adaptability, while reducing the development cost, we propose in this chapter a software framework that aims at reducing the development time and cost of new VR+haptics systems, through the use of well-known software design patterns (Model/View/Controller, Strategy, Observer) and freely available technologies (XML, PhysX).

Low-Cost, Home-Oriented Neuro-Patient Monitoring

Despite the extremely high medical cost of neuro-disorder diseases (NDDs), up to this point we still rely on labor-intensive observations to determine neuro-disorder symptoms. Therefore, it is critical to design a gait anomaly and motor disorder (GAMD) recognition system for accurate capture of NDD symptoms. Such an automatic GAMD monitoring system has to be low-cost, and uses highly motion-sensitive sensors and accurate GAMD pattern recognition algorithms. In this chapter we have introduced our low-cost, home-oriented system architecture that aims to monitor neurodisorder patients. Our system can be used for both daytime and nighttime patient motion disorder monitoring, and link those motor disorders to specific neuro diseases. The three major contributions of this research are: (1) Adaptive determination of GAMD observation window size via on-line signal segmentation; (2) Nighttime motor disorder capture through multi-manifold fusion and learning; and (3) Daytime accurate capture of abnormal gaits through delicate signal pattern analysis. We also proposed to use both in-lab and practical clinical test to study the performance of the low-cost, home-oriented neuro-disorder monitoring platform the ItMAGIC mechanisms.

A Kinect-Based Biomechanical Assessment of Neurological Patients' Motor Performances for Domestic Rehabilitation

Stroke is one of the main causes of disability in Western countries. Damaged brain areas are not able to provide the fine-tuned muscular control typical of human upper-limbs, resulting in many symptoms that affect consistently patients' daily-life activities. Neurological rehabilitation is a multifactorial process that aims at partially restoring the functional properties of the impaired limbs, taking advantage of neuroplasticity, i.e. the capability of re-aggregating neural networks in order to repair and substitute the damaged neural circuits. Recently, many virtual reality-based, robotic and exoskeleton approaches have been developed to exploit neuroplasticity and help conventional therapies in clinic. The effectiveness of such methods is only partly demonstrated. Patients' performances and clinical courses are assessed via a variety of complex and expensive sensors and time-consuming techniques: motion capture systems, EMG, EEG, MRI, interaction forces with the devices, clinical scales. Evidences show that benefits are proportional to treatment duration and intensity. Clinics can provide intensive assistance just for a limited amount of time. Thus, in order to preserve the benefits and increase them in time, the rehabilitative process should be continued at home. Simplicity, easiness of use, affordability, reliability and capability of storing logs of the rehabilitative sessions are the most important requirements in developing devices to allow and facilitate domestic rehabilitation. Tracking systems are the primary sources of information to assess patients' motor performances. While expensive and sophisticated techniques can investigate neuroplasticity, neural activation (fMRI) and muscle stimulation patterns (EMG), the kinematic assessment is fundamental to provide basic but essential quantitative evaluations as range of motion, motor control quality and measurements of motion abilities. Microsoft Kinect and Kinect One are programmable and affordable tracking sensors enabling the measurement of the positions of human articular centers. They are widely used in rehabilitation, mainly for interacting with virtual environments and videogames, or training motor primitives and single joints. In this paper, the authors propose a novel use of the Kinect and Kinect One sensors in a medical protocol specifically developed to assess the motor control quality of neurologically impaired people. It is based on the evaluation of clinically meaningful synthetic performance indexes, derived from previously developed experiences in upper-limb robotic treatments. The protocol provides evaluations taking into account kinematics (articular clinical angles, velocities, accelerations), dynamics (shoulder torque and shoulder effort index), motor and postural control quantities (normalized jerk of the wrist, coefficient of periodicity, center of mass displacement). The Kinect-based platform performance evaluation was off-line compared with the measurements obtained with a marker-based motion tracking system during the execution of reaching tasks against gravity. Preliminary results based on the Kinect sensor suggest its efficacy in clustering healthy subjects and patients according to their motor performances, despite the less sensibility in respect to the marker-based system used for comparison. A software library to evaluate motor performances has been developed by the authors, implemented in different programming languages and is available for on-line use during training/evaluation sessions (Figure 1). The Kinect sensor coupled with the developed computational library is proposed as an assessment technology during domestic rehabilitation therapies with on-line feedback, enabled by an application featuring tracking, graphical representation and data logging. An experimental campaign is under development on post-stroke patients with the Kinect-One sensor. Preliminary results on patients with different residual functioning and level of impairment indicate the capability of the whole system in discriminating motor performances.

Wearable Power Assist Robot Driven with Pneumatic Rubber Artificial Muscles

Recently, the attention has been focused on developing a wearable power assist robot by installing an actuator, such as motors, in the body and assisting and enhancing muscular power; there has been a considerable increase in research and development in some institutes and companies worldwide. Various types of wearable power assist robots have been proposed to support the upper and lower limbs, waist, and so on, which are to be used for the operational support of elderly and disabled people, nursing care work, and heavy lifting work in production sites. Some of them have been commercialized and their promotions have been advanced. Their social needs are extremely high, and there is an expectation of further improvements of assisting effect, installation performance, safety and convenience and affordability. In this paper, after the current state of research and development of this kind of robot is outlined, and our researches on pneumatic rubber artificial muscles, exoskeleton type standing motion assist devices, and wearable, lightweight, and soft power assist robots without an exoskeleton are introduced.

Design and Control of a Hand-Assist Robot with Multiple Degrees of Freedom for Rehabilitation Therapy

This chapter focuses on a patient self-controlled rehabilitation system using our developed exoskeleton-type hand-motion-assist robot and tele-rehabilitation. The virtual reality-enhanced new hand rehabilitation support system, which we have developed for stroke patients in the acute stage, is aiming to allow such patients to conduct every day exercises by themselves without supervisors. This system features a multi-DOF motion assistance device, a virtual reality interface for patients, and a symmetrical master-slave motion assistance training strategy called ”self-motion control”, in which the stroke patients' healthy hand on the master side creates the assistance motion for the impaired hand on the slave side. Moreover, a tele-rehabilitation system consisting of a hand rehabilitation support system for the patients, an anthropomorphic robot hand for the therapist, and a remote monitoring system for diagnosing the degree of recovery is explained.

Virtual Reality Enhanced Robotic Systems for Disability Rehabilitation

This chapter mainly introduced the virtual reality as many benefits of robots involved in disability rehabilitation. According to the vision feedback and force feedback, the therapist can adjust his operation. Virtual reality technology can provide repeated practice, performance feedback and motivation techniques for rehabilitation training. Patients can learn motor skills in a virtual environment, and then transfer the skills to the real world. It is hopeful to achieve satisfactory outcome in the field of rehabilitation in the future. VR is mainly used for the upper-limb rehabilitation robot system in this article. The objective of robotic systems for disability rehabilitation are explored to divide the whole rehabilitation training process into three parts, earliest rehabilitation training, medium-term rehabilitation training and late rehabilitation training, respectively. Accordingly, brain-computer training modes, the master-slave training modes and the electromyogram (EMG) signals training modes are developed to be used in rehabilitation training to help stroke patients with hemiplegia to restore the motor function of upper limb. Aimed at the rehabilitation goal, three generations of VR rehabilitation system has designed. The first generation of VR rehabilitation system includes haptic device (PHANTOM Omni), an advanced inertial sensor (MTx) and a computer. The impaired hand grip the stylus of haptic device, the intact hand can control the impaired hand's motion based on the virtual reality scene. The second generation of the VR rehabilitation system is the exoskeleton robots structure. Two virtual upper limbs are portrayed in the virtual environment, simulated the impaired hand and the intact hand, respectively. The third generation is a novel VR-based upper limb rehabilitation robot system. In the system, the realization of virtual reality environment is implemented, which can potentially motivate patients to exercise for longer periods of time. Not only virtual images but also position and force information are sent to the doctors. The development of this system can be a promising approach for further research in the field of tele-rehablitation science.

Significance of Virtual Reality-Based Rehabilitation in Acquired Brain Injury

Recent research has shown the potential of Virtual Reality (VR) in the field of rehabilitation, namely neurocognitive rehabilitation. This technology will certainly revolutionize the rehabilitation of the future. Its advantages include greater ecological validity than conventional rehabilitation methods, provision of safe contexts for learning/training, the possibility of programs to be contingent on patient performance, with increasing levels of task difficulty and provision of immediate feedback, and the use of a “game factor” that promotes motivation for participation. These are important aspects in the rehabilitation of patients with acquired brain injury. Patients with this and other types of neurological injuries endure cognitive deficits that cause difficulties in independent functioning and daily-life activities. Their rehabilitation calls for systematic intervention programs that are theoretically grounded and use innovative approaches to their advantage. In this paper we present a review about the advantages of VR in the generalization of acquired skills to real-life contexts, to promote patients' functionality and quality of life, and propose an innovative program of neurocognitive rehabilitation. Research in the field shows positive effects of VR programs, but urges progress in terms of the development of techniques (e.g., facial synthesis and of more research on the impact of these interventions. Future studies should also explore the existence of neuro-anatomical correlates of behavioral changes, contributing to the investigation of the relationship between neural plasticity and behavior and providing evidence for clinical practice.