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.