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ICVR2013 Workshop: Designing an effective rehabilitation simulation
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Transcript of ICVR2013 Workshop: Designing an effective rehabilitation simulation
Sergi Bermúdez i BadiaInv. Assist. Prof., Universidade da Madeira
Marie Curie Research Fellow, Madeira – ITI
University of PittsburghDepartment of Occupational Therapy
NeuroRehabLabhttp://neurorehabilitation.m-iti.orgUniversidade da Madeira / Madeira – ITI
Sergi Bermúdez i BadiaMónica S. Camerião
Athanasios VourvopoulosAna Lúcia dos Santos Faria
Quality of Life Technologies Center http://www.cmu.edu/qoltCarnegie Mellon University
Daniel P. Siewiorek
Scott Bleakley
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Myomo Inc http://www.myomo.com
Steve KellyEla Lewis
SPECS - http://specs.upf.eduUniversitat Pompeu Fabra
Paul F.M.J. Verschure
PERCRO - http://www.percro.orgScuola Superiore Sant'Anna
Antonio Frisoli
Hospital del MarMedicina Física i Rehabilitació
Esther Duarte Oller
• Our approach (not necessarily the best one)• The process for developing, designing and testing an
effective rehabilitation simulation– Only Stroke– Particular case of upper limb rehabilitation– Not going to explain or justify the use of VR
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
– Not going to explain or justify the use of VR
• Metrics for simulated movement performance and monitoring
• Personalization using the metrics• Lessons learned from different studies• Open source / game engines for rehabilitation
activities
1. The process for designing, developing and testing an effective rehabilitation simulation
hypothesis
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
where
- Designing defining
- Developing formulating and implementing
- Testing clinical validation
Optimal rehabilitation guidelines
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
VR and Serious Games HCI
Optimal rehabilitation guidelines
Neuroscience
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
VR and Serious Games HCI
1. Treatment frequency and intensity correlate with recovery (Kwakkel et al., 2004; Sonoda, Saitoh, Nagai, Kawakita, & Kanada, 2004).
deployment
2. Movement practice and repetition play a fundamental role in
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
2. Movement practice and repetition play a fundamental role in recovery (Karni et al., 1995).
simulated task / game mechanics
3. Specificity of rehabilitation training with respect to the deficits and required functional outcomes has an impact on recovery (Krakauer 2006).
Interface technology & personalization
- The brain has the capability to reorganize itself in such a way that alternate brain areas
take over other functions. The best way to
stimulate this reorganization is still under discussion, and several approaches have been proposed.
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
proposed.
- Stroke rehabilitation should focus on
maximizing cortical reorganization.Dobkin, Nat ClinPractNeurol 2008
- VR can provide:
- Fully controlled environments
- Minimally supervised intensive training
- Task-specific movement reiteration
- Individualized training
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
- Feedback for reward and motivation
- Mirror Neuron System: neurons that areactive both, during the execution of goal-oriented movements and during theobservation of the same action performedby others.1-3
- There is strong evidence of the existence
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Rizzolatti & Fabbri-Destro, Exp Brain Res 2010
- There is strong evidence of the existenceof a Mirror Neuron System (MNS) in thehuman brain.3-5
1di Pellegrino et al., Exp Brain Res 1992; 2Gallese et al., Brain 1996; 3Rizzolatti & Fabbri-Destro, Exp Brain Res 2010;4Iacoboni et al., Science 1999; 5Buccino et al., Eur J Neurosci 2001
- VR can provide:
- Fully controlled environments
- Minimally supervised intensive training
- Task-specific movement reiteration
- Individualized training
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
- Feedback for reward and motivation
1Gazzola et al., Neuroimage 2007; 2Maeda et al., J Neurophysiol 2000
The Rehabilitation Gaming System: Spheroids
- Moreover:
- MN can be activated through the
observation of artificial agents.1
- Evidence that a first-personperspective is the optimal frame of reference during action observation.
2
BRAIN
- Generation of Sensory Motor Rhythms- Use of remaining Cortico-Spinal Tracts - Close the sense-act loop
- Activation of Mirror Neuron System- Optimal Rehabilitation Guidelines
- Feedback & motivation
VR
Trade-off:
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Trade-off:
In general, the more specific an exercise is…the more complex the interface is…and the more difficult deployment is …
Active movement against gravity/friction
Body movement Finger flexion Tangible interaction
BRAIN
- Generation of Sensory Motor Rhythms- Use of remaining Cortico-Spinal Tracts - Close the sense-act loop
- Activation of Mirror Neuron System- Optimal Rehabilitation Guidelines
- Feedback & motivation
VR
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Natural User Interfaces (NUI)
Active movement against gravity/friction
Body movement Finger flexion Tangible interaction
BRAIN
No movement against gravity/friction
- Generation of Sensory Motor Rhythms- Use of remaining Cortico-Spinal Tracts - Close the sense-act loop
- Activation of Mirror Neuron System- Optimal Rehabilitation Guidelines
- Feedback & motivation
VR
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Natural User Interfaces (NUI)
Adapted / Assistive Interfaces
Passive assistance Active assistance
* mpower 1000, myomo inc.* Armeo, Hocoma
Active movement against gravity/friction
Body movement Finger flexion Tangible interaction
BRAIN
No movement against gravity/friction
- Generation of Sensory Motor Rhythms- Use of remaining Cortico-Spinal Tracts - Close the sense-act loop
- Activation of Mirror Neuron System- Optimal Rehabilitation Guidelines
- Feedback & motivation
VR
Interaction based on:
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Natural User Interfaces (NUI)
Adapted / Assistive Interfaces
Passive assistance Active assistance
* mpower 1000, myomo inc.* Armeo, Hocoma
No active movement
Brain Computer Interfaces (BCI)
Mental Imagery / Neurofeedback approaches
* international 10/20 system
* Armeo, Hocoma
Interaction based on:
- Movement (body kinematics):- Range of Movement (ROM)- Movement speed- Movement latency- Movement smoothness- Muscle synergies- Movement Coordination- EMG
- Autonomic Nervous System (EDA, respiration, HR, etc…)- Brain activity (EEG, NIR, fMRI, etc…)
- Limiting perceived factors in elderly population:
- Perceived barriers due to physical limitations1,2,3
- Lack of knowledge4,5
Study:
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
1Opalinski, J Technology in Human Services 2001; 2Peacock et al., Eu J of Ageing 2007; 3Ng, Educational Gerontology2008; 4Carpenter et al., Computers in Human Behavior2007; 5Saunders, Educational Gerontology 2004. Rubio et al., Presence 2012
- 8 participants with upper limb deficits ( 4 male + 4 female, M= 44.8 yo, not all strokes)- 3 out of 8 subjects reported previous computer experience.- Mouse + keyboard vs.Key-glove comparison.
- Limiting perceived factors in elderly population:
- Perceived barriers due to physical limitations1,2,3
- Lack of knowledge4,5
Study:
- 8 participants with upper limb deficits
t-test, p = .02
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
- 8 participants with upper limb deficits ( 4 male + 4 female, M= 44.8 yo, not all strokes)- 3 out of 8 subjects reported previous computer experience.- Mouse + keyboard vs.Key-glove comparison.
Rubio et al., Presence 2012
1Opalinski, J Technology in Human Services 2001; 2Peacock et al., Eu J of Ageing 2007; 3Ng, Educational Gerontology2008; 4Carpenter et al., Computers in Human Behavior2007; 5Saunders, Educational Gerontology 2004.
Originally developed by psychologists Robert M. Yerkes and John Dillingham Dodson in 1908
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Yerkes & Dodson , 1908
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Cameirão et al., J Neuroeng Rehabil 2010
Hitting Catching Grasping
Automated procedure for difficulty adjustment:
• Task individualization
• Optimized level of performance
• Adapts to individual arms
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Cameirão et al., J Neuroeng Rehabil 2010
• Adapts to individual arms
- VR and real counterparts:
- Are they equivalent?
- Comparison with control group
- The calibration task is used
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
- The calibration task is used to measure arm kinematics and to set the baselineparameters of the training for every session.
- Range of Movement (ROM), movement latency, movement speed.
- Extracted from RGS calibration
- Groups showed a dissimilar pattern of
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
*p<.05, Mann-Whitney Test
dissimilar pattern of improvement in the speed of the paretic arm over time (ANOVA, p<.05).
Cameirão et al., Rest NeurNeursc, 2011.
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Cameirão et al., J Neuroeng Rehabil 2010
12 stroke patients and 10 controls were exposed to random combinations of the 4 game parameters
4-factor ANOVA to disclose main and interaction effects
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Cameirão et al., J Neuroeng Rehabil 2010
4-factor ANOVA to disclose main and interaction effects
Multiple regression to estimate constants (m0 ... m9)
- Not all VR parameters may be relevant
- Parameters interact in a non-trivial an non-linear manner.
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Cameirão et al., J Neuroeng Rehabil 2010
linear manner.
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Cameirão et al., J Neuroeng Rehabil 2010
- 9 stroke patients and 10 controls
- The model captures the behavior of the individual arms by different game parameters, and to adapt
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
parameters, and to adapt the difficulty level accordingly.
Cameirão et al., J Neuroeng Rehabil 2010
Performance
*p<.05, T-Test
Training paradigm:- Goal oriented and repetitive actions- Bimanual training (non-paretic arm support)- Parameterized (flying speed, turning speed, acceptance radius,
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
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)Bermúdez i Badia, Stroke Research & Treat, 2012
A first study with 10 healthy participants
has shown that the NTT captures precise
quantitative kinematic information during a NTT training session, including:
ROM
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
• 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
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*speed
2 + c12*turning2 + c13*acceptance
2
+ c14*distance2
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Movement SmoothnessRange of Motion
Arm DisplacementArm coordination
- Not all parameters contribute to all movement kinematic measures
- We have a quantitative way of adapting parameters depending on a higher leveldesired kinematic training
RGS Control
IOT
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
- N = 16 acute stroke patients
- 3 weekly 20 min sessions during 12 weeks
NSG
Cameirão et al., Rest NeurNeursc, 2011.
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
- RGS group recovers faster than Controls, but not at follow-up Accelerates recovery
- RGS ≥ extended OT
- Reduces therapy costs
Cameirão et al., Rest NeurNeursc, 2011.
N = 44 chronic stroke patients
5 weekly 30 min sessions during 4 weeks
1. NUI interface
2. Haptic interface (GRAB, PERCRO):
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Cameirão et al., Stroke, 2012.
2. Haptic interface (GRAB, PERCRO):
- Force-feedback
- Increase in the ecological validity of the task
3. Exoskeleton (ARMEO, Hocoma):
- Support against gravity
- Control of trunk movements
- All groups improvedsignificantly
- The haptics group retained during a longer period of time
include if possible
- The exoskeleton group
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
*p<.05, **p<.01, Wilcoxon Test
Within-groupBetween-group
- The exoskeleton group showed a “poorer” improvement at proximal movements
not all assistance is always helpful
Functional vs. correct movement
Cameirão et al., Stroke, 2012.
- 9 naïve healthy subjects (26.4±4.2 years)- 3 experimental conditions
Combined motor execution and motor imagery in VR seems to be more effective at:
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
effective at:
- Driving cortical sensorimotor areas1, - Increasing attention and alertness to
task2,- Engaging additional related networks
(cross-modal sensory processing3 or short term memory).
1 Solodkin et al., 2004; 2 Egner et al., 2004; 3 Kanayama et al., 2007
Bermúdez et al., IEEE Trans Neur Sys Reh Eng, 2013.
1 Solodkin et al., 2004; 2 Egner et al., 2004; 3 Kanayama et al., 2007
-18 right-handed healthy subjects (24±3 years)- Active and imagination conditions using RGS
Imagery of target catching was related to activation of frontal, parietal,
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
to activation of frontal, parietal, temporal, cingulate and cerebellar regions, consistent with:
- object processing,- motor intention,- attention,- mirror mechanisms.
Prochnow et al., Eu Journal of Neuroscience, 2013.
- Virtual Environments are simulations that engage the senses of users through real-time 3D graphics, audio and interaction to create an experience of presence within an artificial world.
- Game Engines bring together large-scale software architectures and programming paradigms to design and implement rendering, collision, physics and animation processes.
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
processes.
Cost Free
Platforms Windows
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Platforms Windows
Community Large & commercial
Programming Development Tools
Learning Curve Fast
CustomizationSource code
available
Torque was used to implement the RGS
http://www.rgs-project.eu
Cost Free
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Platforms Win, Mac, Linux
Community Developers
Programming Python
Learning Curve Slower
CustomizationSource code
available
Panda3D was used to implement the NTT
http://neurorehabilitation.m-iti.org/NTT
Cost ~ 1500$ / developer
Platforms All
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
CommunityVery large & commercial
ProgrammingIntegrated
Development Environment
Learning Curve Very Fast
CustomizationUsing external
libraries
Unity is used in the RehabNet project
http://neurorehabilitation.m-iti.org/rehabnet
Cost Free ~ 1500$ / developer Free
Platforms Windows All Win, Mac, Linux
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
Community Large & commercialVery large & commercial
Developers
Programming Development ToolsIntegrated
Development Environment
Python
Learning Curve Fast Very Fast Slower
CustomizationSource code
availableUsing external
librariesSource code
available
• A close dialog between health practicioners – neuroscientists –technologists is necessary
• Our systems are not the end product, are the hypotheses
• Hypotheses need validation impact assessment
• We believe that positive effects of gaming in rehabilitation training do not emerge out of superficial “gamification” of therapies.
ICVR 2013: Designing an effective rehabilitation simulation ICVR 2013: Designing an effective rehabilitation simulation -- 26/08/2013 26/08/2013 -- PhiladelphiaPhiladelphia
emerge out of superficial “gamification” of therapies.
• Game / training mechanics need to include:
• Neuroscientific principles of recovery
• Difficulty vs skill needs to be quantified and well understood
• Game parameters need to be automatically personalized
• Stress levels need to be controlled to ensure maximal performance and consequent maximal learning
For more information contact:
[email protected]@uma.pt
or visit
http://neurorehabilitation.m-iti.org