Thoughts on a Monday morning – 30 MAY, 2010.

We humans interact with ourselves many times more than we do with the outside world (Harris, 1998; Taylor, 2009). So far technology has attempted to enhance our experience with external communication and interaction. This seems to have resulted in an over-engagement with the outside world, naturally at the cost of time spent with ourselves. As A Parallel line of thought, over the past decade, evidence from epidemiological studies and clinical trials has demonstrated a positive association between physical fitness and psychological health. Numerous studies have shown that physical activity and exercise as well as mind-body practice reduce morbidity and mortality for coronary heart disease, hypertension, obesity, diabetes and osteoporosis, and improve the psychological status of the general population (Janisse et al, 2004; Chou & Tsang, 2007; Smith et al, 2007; Broman-Fulks & Storey, 2007; Tsang et al, 2008).

Yoga, martial arts and traditional health systems of the East and Far East, have emphasized the benefits of increased internal communication for thousands of years. A heightened awareness of this internal interaction between our mind and body systems has been credited not only with longevity and disease free living, but also with happiness, spiritual advancement and purposeful living well into old age. Even today, people from all walks of life seek out spiritually aware people and “gurus” for advice on problems that medicine and money cannot solve. Those who find a good teacher and ultimately overcome their personal challenges and attain happiness, are still rare in comparison to the general population who are “in search”. Many of us see this everyday in the world around us.

The problem with this heightened awareness of the internal communication, whether through yoga, martial arts or any other system, is that it takes years to achieve, even for perfectly “healthy” people. The question, therefore, is:

Just as technology has made external interaction so much easier, can technology also make the internal interaction, between the mind, the body, the breath and the spirit, easier and more effective so as to benefit people of all walks of life?

Is it possible for us to create a tool that will help us to “see” and “feel” this conversation between our mind and our body, within ourselves as users and in others, as researchers?

I strongly believe that this endeavour will be one of the most powerful quests of the human race later in this century, perhaps more than clean energy and a solution to terrorism.

What will be the first steps in any attempt to seed such a technology ?

• THE first step is to reverse what science and medicine has been doing for the past few hundred years - the separation of the mind and the body - in research and study. Great technologies and algorithms have been developed to study the body, brain, breathing and circulation in the human body separately and individually. It is required to bring all these together in a visible, auditory or kinesthetic form of biofeedback for a person to experience how they work together and how changes in one affects the other.
  
• Next, build curiosity and challenge through a gaming environment which demands a balance in mind, body and breath awareness, rather than just great motor control (PlayStation) or mind control (NeuroSky), as is fashionable these days.
  
• Next, make the technology open-ended so that all sorts of everyday devices, assistive and rehabilitation technologies and even educational software can communicate and take inputs from this technology in a “plug-n-play” format.
  
• Lastly, make it portable and affordable for individual ownership in the third world.
  

While we are doing the above, we must continue the practice and study of yoga and martial arts and search for the obvious meeting points with technology in a more meaningful way. Most spiritual practices around the world, advanced or primitive, believe that once we are aware of the unity (yoga : “union”) of the mind, body and breath, it helps us to gain not just good health but also access to the so-called spirit. This raising of the spirit, I believe, is a primary pre-requisite for independent and fruitful living, irrespective of whether we are children with learning issues, professionally successful adults or senior citizens grappling with problems of ageing.

Technology, if designed right, can be a great tool to help facilitate this union process. This will probably change the world in a manner far more dramatic than the internet or the mobile phone.

References

Harris, J.E. (1998). How the brain talks to itself. The Howarth Press Inc., USA, 19-35.
Taylor, J.B. (2009). My stroke of insight. Hodder & Stoughton, UK, 147-158.
Janisse HC, Nedd D, Escamilla S, Nies MA (2004). Physical activity, social support, and family structure as determinants of mood among European-American and African- American women. Women Health 2004, 39:101-116.

Chow YW, Tsang HW: Biopsychosocial effects of qigong as a mindful exercise for people with anxiety disorders: a speculative review. J Altern Complement Med 2007, 13:831-839.
Smith PJ, Blumenthal JA, Babyak MA, Georgiades A, Hinderliter A, Sherwood A: Effects of exercise and weight loss on depressive symptoms among men and women with hypertension. J Psychosom Res 2007, 63:463-469.
Broman-Fulks JJ, Storey KM: Evaluation of a brief aerobic exercise intervention for high anxiety sensitivity. Anxiety, Stress & Coping 2008, 21:117 - 128.
Tsang HW, Chan EP, Cheung WM: Effects of mindful and non-mindful exercises on people with depression: a systematic review. Br J Clin Psychol 2008, 47:303-322.

Poll Results for July, 2009

Here are the results of the recent poll conducted on this blog....

The question:
"Would you buy a robotic rehabilitation device for yourself or a family member trying to cope with a paralysed limb?"

Answers : 1. Yes 35%
2. No 0%
3. I dont know what is a robotic device 5%
4. I will do as my doctor says 15%
5. Only if it is value for money 41%

total respondents over a two week period ( I should have kept the poll open longer) were 17. The respondents were unknown although I know the poll was circulated to users and care givers through my friends. I would interpret this as representing a general interest in robotic rehab devices and a specific interest in cost-effective robotic solutions, particularly home-based since the poll is about purchasing such as device.

Now the question to all of you is.....what would make such a device cost-effective and "value" for money?

So do respond to this month's poll.....

A great Care Giver's Guide from Canada....

This is a great piece of work.....done with a lot of effort and love. I recommend it to everyone, especially care givers!!

http://www.strokerecoverycanada.com/srcEnglish/english/StrokeGuideEnglish.pdf

Just wishful thinking....or Real Possibilities?

Can we, technologists and users, change the world we create and function in?
Dare we.....

• Design robotic devices to cost - for home use.

It makes business sense to sell a 100,000 robotic rehab devices (thats less than 1% of the world's disabled population) annually costing USD 5000 rather than a 500 pieces annually costing USD 100,000. Most technology companies are doing the latter.

• Adopt Universal design principles for greater social inclusion

There are no clear biological indicators yet that a disabled person will recover completely through therapy. In such a case, can we still achieve social inclusion and integration? Can we create rehab devices which the whole family can use, therapy for those who need it , biofeedback training, collective play, etc. for healthy family members for health enhancement and fun?

• Certification as a fringe benefit to regained motor function

There is a need to view the disabled person as a potential social resource rather than a burden. Their population is skyrocketing so we might as well. Can a person who has mastered the use of a robotic device and regained, say, 80% of his motor function, be "certified" as a trainer for recent patients, under the guidance of therapists?

• Pay back in future

Can we design devices which will generate revenue for the user in the long run? How many ways can we devise for the user to see it as a worthwhile investment?

• Modular design with Plug and Play compatibility

No robotic device currently seamlessly communicates with any other, although each one has their own positive and negative features. Considering the diversity of functional impairments and the fact that the user requirements change with progress in rehab, which hospital will be able to provide comprehensive facilities without a massive investment?

• Converting home use items into rehab devices

Can a wrist flexion operate a TV remote or a quaricep contraction click a mouse? This will increase clinical relevance as well as number of daily repetitions in practiceCan we bring into the design not just activities of daily living (ADL) but also activities of daily enjoyment (ADE)? This is within the reach of current technology.

• Mobile systems which communicate

Can a rehabilitation robotic device go wherever the user wants it to go. Can it have internet access to transmit data and to download new routines/games/music over the net which enriches the prescribed rehab protocol? It is within the reach of current technology.

• Making a person "whole" again

The technology we possess today demands a new definition of "quality of life"(QOL). We can attempt to give a richer life experience to the user by incorporating in the device, features which integrate body, mind, spirit and society/environment - in short bringing together a person's inner and outer worlds and weaving a beautiful bowstring.

Is the Generation Gap the Answer to the Digital Divide in Rehab Technology?

There is a lot of research being done in the areas of learning and social interaction for both normal, developing children as well as children with special needs. Recently there has been promising results using simple robots as an aide to such development through solitary and collaborative play (AURORA project).

On the other hand, the history of use of robotic devices for rehabilitation of motor function in stroke patients is much longer, starting somewhere in the early 1960s. But the gains have not been dramatic and the continued usage by patients abysmal.

There is strong evidence that robotic rehabilitation devices have become merely “exoskeletons with / without bio-feedback” and in some cases “active orthoses”, rather than being designed as devices which enable self expression in learning and play. There is no doubt that the active orthoses and the bio-feedback have shown positive results but full recovery occurred largely in cases where the motivation levels of the patients were high.

Therapy with children struggling with Autism and a patient trying to come to terms with the aftermath of stroke may have common elements due to the following similarities:

1. In both children as well as adults who have recently suffered cerebral trauma, the brain is in an elevated level of neuroplasticity for a particular, limited time-window.

2. Both groups suffer from low self-image and low social interaction.

3. Both groups have very short attention spans and inability to hold focus (especially if the stroke patients have some aphasia)

4. Both groups may have related issues with motor function.

5. Motivation to change in both groups is largely low.

6. Among the normal population, both age groups find great pleasure, security and energy interacting with each other, across all cultures.


The emerging concept of “Collaborative therapy” where two patients collaborate with each other or with their care givers or friends or with growing children shows great promise, in that it re-introduces the patient ( who has felt isolated so far as an invalid ) into the social milieu. Using universal design principles in the design of such “Orthotic Play and Collaborative Devices” will enable the patient to interact with whosoever he or she pleases, be it an infant or an elderly friend, able bodied or physically/mentally challenged.

So far, the case of interactive play has been seriously addressed only by Virtual Reality, where a patient is able to respond to / elicit response from a virtual object or person. But the experience of interacting with a real person is far richer and more stimulating to the various senses. It also brings into play more hand movements and upper extremity manipulations rather than being restricted to a mouse or a joy stick, and a computer screen. The participants may also use more natural positions to re-learn, rather than get stuck with a “table top” mindset.

We feel the coming together of two disciplines, robotics/mechatronics and learning behaviour, can give a boost to the accelerated recovery of patients living sub-optimal and dependent lives due to stroke. Hence it may be worthwhile to explore a study where these two disciplines work together to identify which interactions are critical to the patients and then design and develop simple robotic toys / devices to easily enable these interactions. These simple, non-screen based devices will also hopefully address the problem of low levels of long term acceptability/ enjoyablity of solely screen based systems for the elderly age-group. Simple therapy and disability assessment aids like the 9 Peg Board, the Purdue Board, Finger Ladder,Weight Well, hand dynamometer or pinch gauge can also be converted to “active play” devices.

In the same way, researched data about children with special needs can be incorporated into robotic design, so that the device becomes a mode of self expression, learning and collaborative play, as has been already tested in the AURORA project. The key again is to enable both normal children as well as children with special needs to use such devices for interaction.

Visualise a scenario where a child with autism or ADHD interacts and plays with an elderly stroke patient through a device which bridges the generation gap and limits the social isolation of both these vulnerable populations, besides aiding rehabilitation in a significant manner. That's something worth a lifetime of research effort !

Intelligent Technologies : New Initiatives to Bridge the Digital Divide

(in collaboration with Dr. John Heng, School of MAE, NTU, Singapore)

Introduction and Concerns

As the pace of life increases, the need for independent living among the aged has been growing. This has been accompanied by increasing populations of aged and disabled elderly in the past two decades, which has resulted in further isolation at physical and emotional levels for the aged.

As a person ages, he finds himself trying harder to remain functional. The motor and cognitive impairment becomes the new reality. This has an immediate impact on the self-image and the patient perceives himself as a dependent and a increasing burden on family and society. This gives rise to new independence and relation needs[1,2]. On the other hand, individuals above 65 years of age may also lose interest in independent living and believe they will never improve[3].

The development of assistive technology has tried to focus primarily on helping the elderly cope with physical tasks, activities of daily living, accessing entertainment and using communication tools to exchange information. Hence the approach has so far been to enable interaction with the outside environment.

We find, however, the usage of such technologies among the aged have not shown the dramatic rise that may have been expected. The low technology objects in both rehabilitation and assistive technology have the highest usage. So it seems that this population is more comfortable with technology that has a high level of usability, even though the device may have a low level of intelligence.

Several bodies of research from medicine, neuroscience and physiology have shown that it is possible to recover or maintain many inherent faculties in the aged, which may have deteriorated from disuse or damage. These include memory, mobility, motor function, audio sensitivity, cognition and so on[4,5,6,]. The self-determination theory [7] states that humans who are naturally motivated tend to incorporate an internal regulation strategy for all important activities. It has been also proven through several studies that attention, motivation and repetitive task practice are essential factors in the reorganization of the brain [8,9,10,]which can take place well into old age.

It seems that the major factors affecting this recovery or maintenance relate to the high level of engagement of the individual with the task at hand. Studies in psychology and accelerated learning also highlight that such high levels of engagement occur when there is an “emotional connect” for the individual to the task and when all sensory pathways like visual, auditory and kinesthetic pathways are brought into play. This can happen when there is a collaborative environment[11].

A New Mission for Assistive Technology

The new mission will be to highlight initiatives being taken in various studies and experiments to develop technological platforms which involve multi-level haptic interfaces. This new approach focuses on usability, simplicity and engagement, thus making choice of device easier.

Such multi-level platforms will make it possible for the aged to re-connect with their own residual capabilities at the physical, cognitive and adaptive levels. At the same time, it will allow interaction with others through artistic expression and collaborative play. Multi-level platforms can be adjusted as the person improves or deteriorates over a period of time.

Building into the basic design a capability of HMHI (Human- Machine-Human Interaction) moves the user away from “Isolation” to a more “Relational” environment, where he or she is able to interact with a living being at various levels. From this perspective, it may be beneficial to design a technological platform that enables

1) Allow sharing of resources such as strength, mobility and motivation between two or more aged persons

2) Allow use of the system in multiple environments, so that it is usable for all levels of impairment and fatigue as well as facilitates more variety in activity

3) Gives elders a chance to integrate with the system at multiple levels with their residual functions, so that they can adjust, communicate and respond faster.

Along with principles of universal design, this new paradigm of design can then be the springboard for a new generation of simple assistive devices which can integrate seamlessly with the user. The graded sensitivity of such devices to the user’s needs, rather than merely its level of intelligence, will enable higher usability and help the aged to integrate with society and the environment.

References

[1] N. Maclean, P. Pound, A critical review of the concept of patient motivation in the literature on physical rehabilitation, British Medical Journal,vol 50(4), 495-506, 2000.
[2] R. Goldberg, Psychosocial aspects of stroke, Rehabilitation Psychology, Kruger DW and Collins LB (Eds.), Rockville: Aspen Publication, 1984.
[3] C.B. Lewis, Rehabilitation of an older person: a psychosocial focus, Physical Therapy, vol 64(4), 517-522, April, 1984.
[4] J. Williams, D. Ramaswamy, et al., 10Hz flicker improves recognition memory in older people, BMC Neuroscience, 7:21, 1471-2202/7/21, 2006.
[5] D.O.Clark, D.E. Stump, Predictors of onset of and recovery from mobility difficulty among adults aged 51-61 years, American Journal of Epidemiology, vol. 148:1, pp. 63-71., 1998
[6] C. Hofgren, A. Bjorkdahl, et al., Recovery after stroke: cognition, ADL function and return to work, Acta Neurologica Scandinavica, 115(2): 73-80, 2007.
[7] E.L. Deci, H. Eghrari, B.C. Patrick, D.R. Leone., Facilitating internalization: the self determination theory perspective, Journal of Personality, vol 62(1), 1994.
[8] Neural Basis of Decision in Perception and Control of Movement, Neurobiology in Decision Making, Springer, 83-100, 1996.
[9] P. Bach-y-Rita, Theoretical and practical considerations in the restoration of functions following stroke, Topics in Stroke Rehabilitation, vol 8(3), 1-15, 2001.
[10] I.H. Robertson, J.M.J. Murre,Rehabilitation of brain damage: Brain plasticity and principles of guided recovery”, Psychological Bulletin, vol 125(5), 544-547, 1999.
[11]R.C.V. Loureiro, M.J. Johnson, et al., Collaborative tele-rehabilitation: a strategy for increasing engagement, Proceedings of the 1st IEEE Int. Conference on Biomedical Robotics and Biomechatronics, , art. 1639198, pp 859-864, 2006.

EXPLORE - THE TRAVAILS OF A PERSON WHO CANT USE HIS HANDS

WHY CAN'T WE DO BETTER THAN WHAT WE HAVE IN THE MARKET NOW?

WHO IS WILLING TO SHARE HIS KNOWLEDGE? LETS CREATE A KNOWLEDGE CENTRE

This is my work so far over the past 6 months. References available on request.

INTRODUCTION & BACKGROUND


Over the past 30 years, statistics has shown the rapid increase in the cases for stroke and spinal cord injury patients in Singapore and in ASEAN. Increasing the demand of Rehabilitation professionals alone is not a ready solution as the duty and responsibilities assigned to the therapists have greatly increased. There is a strong need to develop an efficient and effective automated Upper Extremity (UE) functional training orthosis that would greatly benefit stroke patients to provide customized and accelerated rehabilitation. An important potential benefit of using robotics and information technology for neurological rehabilitation evaluation is that it permits new measurements that will provide deeper insight into the severity of impairments or degenerations and the sensory motor consequences in patients with neurological impairments (Roher, 2002; Finley, 2006). Many researchers of developing UE robotic trainer have shown promising results, eg. MIT-Manus, MIME and ARM Guide. The first robotic therapy study was conducted with MIT-Manus, confirmed that robots could be used as effective tools to aid in rehabilitation of movement deficits by increasing the amount of therapy delivered to acute stroke patients (Leonard, 2003). When compared to conventional treatments, robot-assisted therapy resulted in larger gains in strength and larger increase in reach extent (Leonard, 2003). However none of existing systems are portable or easy to wear. It is for these reasons, that this project aims to develop a unified UE rehabilitation orthosis platform to address the current short comings.

Research proposal

Our hypothesis is to help acute stroke patients to acquire a better and more functional recovery through the use of robotic technology with the proper design of a customised orthosis.
Results from many research & patients feedback is that patients desire for recovery of their upper limbs functions (in terms of grasping, wrist and forearm control) are the most important function for them so that patients can perform their Basic Activities in Daily Living (BADL).
The aim of this project is to develop a Unified platform to achieve Accelerated Functional Return of Grasping, Wrist and Forearm Control in Stroke Patients with EMG Actuated UE Orthosis.
When we combine the use of the robotic technology with the proper design and use of the orthosis, we can help acute stroke patients to acquire a better and more functional recovery. The final efficacy of such a proposed system can be measured by using FIM and Fugl-Meyer assessments for functional outcomes.
The research will be working closely with the senior therapist and Rehabilitation Physicians at TTSH rehabilitation centre as well as to gain access to their ready source of stroke patients. An international expert Professor of Rehabilitation Engineering from SMI have been brought on board as a co-investigator to allow the team to leverage on his expertise in this area. It is the aim of this project to allow Singapore to establish and gain expertise in the area of robotic assisted active rehabilitation which is currently not available in Singapore. As the population of Singapore and that of the region steadily ages, this is an area of concerned which should be addressed with urgency.

Clinical Significance

Current literature shows that a lot of work has been done on lower limb orthosis but comparatively less on upper extremity, especially orthosis for grasping and pronation / supination. Data from TTSH, speaking to stroke patients and information published from various research papers indicates that the most important function that the patient wishes to recover urgently after a stroke episode is that of grasping, wrist and forearm control, so that they can be self sufficient in feeding, bathing, and clothing themselves as well as being able to resume handling visits to the toilet alone.

We find that after extensive literature review that a lot of work has been done on FES-based systems, patient activated virtual reality systems, different types of rehabilitation protocols ( eg. Restraining unaffected arm ) and so on. All the above have had their positive results in their own ways and have contributed greatly to the understanding of motor and neuromuscular rehabilitation.

However, there has been very little work done in trying to bring together on a single platform all the critical elements of the studies conducted, so that the orthosis is versatile, simple, affordable, and effective.

According to several works on rehabilitation by various researchers, the key elements of recovery in rehabilitation should include :

1. Ability to generate an isometric preactivation of sufficient strength voluntarily
2. Ability to perform complete functional ROM for each joint
3. Ability to generate sufficient force in grasping action and other movements
4. Recovery of functional capabilities rather than isolated movements eg. Feeding oneself while holding a spoon, tracing a pattern with fingertip, combing hair, picking up and placing objects, etc.

Preliminary Data

Currently in the market, there are the NeuroHand and NeuroMove available for UE FES and EMG based UE training. The NeuroHand incorporates FES and a forearm based (covers up to the wrist joint) hand orthosis. There is a controller box which can adjust the frequency and amplitude of the FES. It provides stimulation to the wrist and finger extensor and flexor muscles once the FES has been turned on with a specific frequency alternating between flexion and extension of the wrist and fingers. It is mainly used for training but no voluntary control of activating of the device by patients themselves. E.g. They cannot hold the flexion of the wrist and fingers as long as they want once the FES starts to stimulate the extension muscles and the hand orthosis only covers up to the wrist. As a result, stroke patients tends to develop a lot of flexor tone over the affected side of the body only. Once the FES activates the forearm extensor muscles, the fingers tend to hyperextend at the MCP joints due to the strong pulling from the flexor muscles. Hence it does not really prevent fingers flexors from further contracting. For NeuroMove, it is a machine that functions based on EMG and FES. The EMG electrodes will be placed on the forearm to detect muscles contraction. From there, the machine will pick up the signal and activate the FES electrodes which is also placed on the forearm to stimulate extensor or flexor muscles. However, there are no hand orthosis to compliment for proper hand positioning during the training.

Methodology

The proposed orthosis will be ergonomically designed. The orthosis will also have the dynamic feature to accommodate the movements of the joints. It will consist of as few parts as possible. For example, if a patient is able to control his proximal UE movement, he then can start with wearing the next distal part of the orthosis for support. The converse can also be true. If the distal movements are recovered first, the orthosis modules for distal function can be discarded and the subsequent proximal module can be worn. As the rehabilitation progresses and the patient improves further, additional parts can be either incorporated or discarded. In this way, the patient will just need to put on the additional pieces for the next stage of training. The proposed orthosis is based on the principle of detecting SEMG of corresponding muscles and then triggering actuators or FES stimulation to facilitate muscle activation of the affected site.
From the above, it was decided to design the robotic arm UE orthosis along the following lines :
1. It should read and record an isometric contraction through SEMG electrodes. If no isometric contraction can be generated by patient, the patient should trigger a FES signal to stimulate the muscle isometrically.
2. It should allow the voluntary movement through complete functional ROM. In case the patient is unable to generate movement, it will be generated by FES or mechanical actuator or both in parallel. The FES and actuator will be triggered by the SEMG or some such trigger which can be controlled by patient. The quality and frequency of the trigger will dictate whether the ROM achieved is partial or complete.
3. The force generation may be supplemented by the FES or actuator.
4. Visual Feedback on a computer screen may indicate which muscles are contracted and how much force is generated. This will be a Boolean display read from SEMG amplitude and frequency of the contracted muscle and will only be indicative for the patient to direct attention to required muscle groups. There may be a benchmark provided based on readings from the unaffected arm.
5. For functional movements contributions from other joints may be assisted manually during testing or automated by add-on plug-n-play attachments for elbow and shoulder ( as part of future work ).
6.The design and construction of the robotic brace will be ergonomically and anthropometrically aligned to reduce unwanted compensation and fatigue.
7. The design and construction of the robotic brace will be light, simple and easy to use at home independently by patient after initial training.
8. The triggers are to be independently adjustable for each channel so that they are applicable to a large cross-section of patients. The patient should be able to independently switch on / switch off the FES and / or actuator, based on progress.
9. The design will be modular, so that after rehabilitation is complete, any or several modules can work as an assistive device depending on which movements are recovered by patient and which are not. Also the patient can move into long term rehabilitation of these movements at home.
10. The combination of FES / mechanical actuator will enable the therapist and patient to balance the continuous loading of muscles with fatigue relief when required. This will enable many more hours of rehabilitation and many more repetitive movements thus enhancing neuromuscular retraining and also preventing muscular disuse atrophy.