Putting stroke rehab technology through its paces
The University of Tasmania is running a new study on the use of Canadian-designed software called Jintronix, which uses the Microsoft Kinect for Windows and virtual games to help people recovering from stroke to complete – and enjoy – their physiotherapy.
Led by UTAS lecturer and physiotherapist Marie-Louise Bird in association with Launceston General Hospital and the Tasmanian Health Organisation – North (THO-North), the randomised controlled trial will involve up to 70 patients using the Jintronix system and individualised therapy compared to traditional group therapy classes.
It will measure physical outcomes such as limb function and general physical activity on the ward using activity monitors, but also how much the client enjoys the therapy and how much time they spend in the program. Initially, the trial will look at outcomes while the patients are still in hospital, but the idea is to extend it to studying the technology when used at home.
While there are a number of other trials taking place around the country into providing stroke rehab at home through video conferencing, such as the University of Queensland's eHab program and Flinders University's Telehealth in the Home project, this trial will use the popular consumer device Kinect along with the Jintronix system, which has been designed specifically for stroke rehabilitation, Dr Bird said.
“The difference with our trial is the commercially available hardware – you can just go down to any retailer and just get a Kinect and a computer,” she said.
“At the moment we are trialling it in the hospital but the next part of the roll-out, and we are hoping to get more funding to make that happen, is to actually to do it in people’s homes.”
Five video game units have been set up in the physiotherapy area of the Launceston Hospital and another two in the THO-North public rehabilitation centre in Launceston. Dr Bird herself is based on the Newnham campus in Launceston but the technology allows for remote monitoring and the quick adjustment of the difficulty level of the exercises.
“For example, some of the software activities are for two minutes and some of them are for five repetitions,” she said. “At the beginning of their therapy, five repetitions might fatigue them and it will take them two or three minutes to do five repetitions. Whereas after they have practiced it for a while, they might do that in 20 seconds.
“I can then go in to the client management part of the system and have a look at the time they are spending in each program, and as well as that it will rate the accuracy.”
The software is able to calibrate the tasks every time they use the program depending on the range they have in their affected arm, using the Kinect motion sensor device. The Kinect also allows the unaffected arm to be used to switch to a new game, meaning they don't have to use a mouse.
The games also use audio and visual cues such as music and colour changes on the screen to tell the client when they have successfully completed the exercise.
Jintronix has a suite of 12 games, and Dr Bird has been working with the Canadian developers to add more levels of difficulty to provide more targeted levels of activity for that individual.
“It actually calibrates every day that they go into the program, how much range of movement they’ve got in their affected arm,” she said. “If I say I want to just have an easy program, it will be easy for the range they’ve got. If I say I want a hard program, it will be hard for the range they’ve got.
“Over the last year we’ve been working with the developers as originally it was just low, medium, hard. Now there’s not only 10 levels of difficulty, but I can actually say, for example with a squatting activity, I want this person to squat 5cm or 10cm. And even within the game, I can just click on a little spanner and instantly change the settings. It’s amazingly configurable.”
The trial currently involves a clinician working with the client to set up the program, but once it is up and running and the parameters are all set, therapy assistants can take over. With the remote monitoring capability, allowing the clinician to see whether the game is too hard or the client is fatigued, it quite easily allows for the program to be used in the client's home.
Dr Bird said the trial was a pragmatic one: the evidence is emerging that high levels of repetition in early physical rehabilitation results is important for good functional outcomes from stroke, and it also helps with concentration when used in association with occupational therapy. Evidence for the use of technology and gamification for rehab is also mounting, as is the need for therapy to be enjoyable.
Physiotherapists use physical activity enjoyment scales, known as PACES or PAE, to measure this factor, and Dr Bird and her team are using research by University of Melbourne physiotherapist Kelly Bower to measure enjoyment. Ms Bower has published extensively on the use of consumer devices such as Nintendo Wii for post-stroke rehabilitation.
“We are using a visual scale that was recently developed and published by Kelly Bower that looked at enjoyability, and with another paper that I’m working on, we've looked at technology with older adults and how they enjoy it,” Dr Bird said.
“We know that, if people enjoy physical activity, they are more likely to take it up and keep going in the longer term.”
The next stage is to recruit clients to use the system at home, such as those discharged into a transition care program, where clients receive therapy support at home for a certain amount of time. This will consist of providing the client with a computer, camera and a WiFi dongle, but does require a bit of IT configuration so the settings are correct.
One of the other trial leaders is Stuart Smith, director of the Healthy Eating, Active Living TecHnologY (HEALTHY) Research Centre, who is working with Dr Bird on extending it to rural communities.
“One of the things we would like to do is have a set-up in a community centre or a community gym,” Dr Bird said. “This could be supported by a health care worker or community champion who has a basic amount of training, and people could just go into the centre to participate in activities remote from their clinician. That way they get a little bit of socialisation, but they don’t have to then travel the 90 minutes to the hospital and 90 minutes back for their therapy.
“For stroke clients, fatigue is a huge thing, but as well for our rural clients you’ve got the other option of do you put the physio or OT in the car and they travel three or four hours. It’s just not a good use of people's time.”
There is also a lot of interest in the technology for children with disabilities but this software itself is not yet designed with children in mind. However, Dr Bird said the back-end technology is just the same.
“There’s a huge amount of applications,” she said. “We are using it for motor control with stroke but I think for just improving physical activity to prevent cardiovascular disease, or for wheelchair-bound children, there’s a huge potential there as well. There’s lots of stuff going on.”
The trial is being funded by the National Stroke Foundation with a $20,000 seeding grant added to financial and in-kind support from the University and the Department of Health and Human Services.
Pictured on our newsletter is University of Tasmania lecturer Marie-Louise Bird, stroke survivor Anita Jupp and THO-North clinical lead physiotherapist John Cannell, courtesy of UTAS.
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