Body Area Network: Implications for Rehabilitation

Dr. Lori Maria Walton, PhD, DPT, MPH(s)Professor & Director of Research

Andrews UniversityMichigan, USA

IntroductionBody Area Networks have numerous applications in medicine and rehabilitation:

Cardiopulmonary

Vascular

Endocrine

Neurological

Physical Medicine

Perioperative monitoring

Clinical Application of

Body Area NetworksAugmentation of Provider-Patient Relationships

Remote health/fitness monitoring

Improve patient autonomy

Remote monitoring systems may be more efficient and cost-effective for the healthcare industry (if sensor cost can be minimized)

Injury Prevention & Sport Training

Feedback systems may be utilized to provide “real time” body position and biomarker information to the patient for self-correction and prevention of injury & rehabilitation from injury

Biomarker diagnosis of disease

Health Care Expenditures

Canada spends 68 billion dollars per year and USA spends 75% of $2 trillion dollar budget on chronic diseases such as diabetes, cardiovascular disease, pulmonary disease, etc.

One third of Canadians have at least one chronic health condition (Brief to House of Commons, 2011)

Patients who are well informed about their medical condition are able to take action to correct it and make behavioral changes accordingly.

Type of Body Data Monitored

Blood pressure, Heart Rate, Respiratory Rate

Body Movements according to specified anatomical landmarks

Biomarkers for acute and chronic disease process

Placement of Body Area SensorsSubcutaneous (biomarkers)

Clothing (external temperature, vital signs, etc.)

Body Part Accessory (Heart monitors, pace makers)

Includes: accelerometers, gyroscopes, smart fabrics and actuators, wireless communication networks, and data capture technology

BAS for

AccelerometersElectrochemical sensors

Measure acceleration of objects in motion

Monitors posture, walking, running, etc

Reference axis landmarks

Provide information on basic steps and activity counts

Quantitative measurement

Velocity and displacement measurement

Triaxial accelerometers (3-D)Provide information on movement 3-dimensions

Posture

Gait analysis

GyroscopesBased on angular momentum (3-D)

Body Chemical Sensors

Glucose MonitorsInfrared sensors

Blood pressureOscillometric

CO2 Gas SensorsMonitors changes in CO2 and O2

ECG Sensors

EMG Sensors

EEG Sensors (Chen et al, 2011)

Pulse Oximetry

Humidity and temperature

Placement of the Body Area SensorsWrist

Ankle

Waist

Chest

Arm

Legs

Subcutaneous and superficial placement depending upon the utilization

*speed, distance, steps taken, floors climbed, calories burned, ambulation, and posture, SpO2, HR, body temps, , ECG, RR, gait, biomarkers such as lactate, glucose, etc..

WBAN

Monitoring Patient reported outcomes (PRO)

Telemonitoring

Quantifying self-hybrid model (QSHM)

Utilization of BAS in Cardiopulmonary

RehabilitationCardiopulmonary & Vascular Monitoring

30% of worldwide deaths are attributed to CVD (WHO, 2014)

BP continuous measurement utilizing US and an actuator

Blood O2 Saturation, Body temperature, and ECG, optical absorption of hemoglobin proteins for blood O2 levels, exercise stress and fatigue levels

Diagnosis of cardiac abnormalities, atrial fibrillation

Electrochemical sensors (in progress) to determine prothrombin time for patients on Warfarin (blood thinner)

DiabetesEMG (long and short sensors) monitor glucose levels (Chen et al, 2011)

Contact lens remotely monitor glucose levels (in progress)

Monitoring of exercise glucose levels for patients with diabetes could potentially create a more individualized specific exercise routine

Peripheral neuropathyBalance rehab utilizing a visual biofeedback system similar to video gaming and body sensors at the ankle and hip to correct motor learning strategies was shown to improve proprioception and postural stability (Grewal et al, 2013)

Neurologic Diagnosis

Gait & Posture Analysis Analysis Parkinson’s Disease (Conceptual model by Cassimassima et al, 2014)

Limb ParalysisMeulen et al, 2015 Optimal guidance of rehab for 13 subjects with stroke utilized 17 sensors in full body ambulatory system to track measurements for maximal reaching distance, vertical reaching range, hand movement relative to sternum & pelvis

Cerebral PalsyTwo sensors placed on low back and R ankle to monitor gait in children with CP (reliability and validity was more predictable in the minimod vs AMP sensors) (Kuo et al, 2009)

Another study (Baram et al, 2011), showed a 21% residual improvement in walking speed & 8% improvement in stride length for children w/ CP and sensor feedback.

Other Measurement

Exercise progression to maximize therapeutic recovery

Pulmonary rehabilitationGraded exercises

Self-management education

Strength & flexibility training

Physical activity

Monitoring of home exercise program

Subcutaneous Biomarker DetectionElectrochemical biochips

Bajj-Rossi et al (2014) proposed utilization of multi-walled carbon nanotubes w/enzyme catalyst to assure sensitivity and specificity of biosensing

Lactate (SN: .77)

glucose (SN: .64)

pH (SN: .75)

temperature (SN=1.08)

Inflammation (C-Reactive Protein) (Fakanya et al, 2014)

Glucose SensorsAmperometric sensor

utilizing enzyme-electrochemical sensors & thick film technology

Fibre Optic fluorometric glucose sensor

based on O2 measurement

Spectroscopic glucose sensor

utilizing mid-infrared spectroscopy

Implications for Women’s Health Rehabilitation

Prenatal/Postpartum DiagnosisMagnetoencephalogram for fetal and maternal monitoring (during activity) (Vairavan et al, 2010)

Brain growth in the fetus

Cardiac anomolies in mother

ObstetricsEarly detection of preeclampsia biomarker predictors including Corticotropin Releasing Hormone and Vitronectin (Song et al, 2015)

Cancer (Hunter et al, 2014)Subcutaneous temperature sensors in mice sample utilized to detect lymph tumor progression (EMu Mic Lymphoma) (r=.68, p<.001)

Common Prenatal Problems

Placenta Previa

Preeclampsia to Eclampsia

Placenta Abruptio

Subchorionic Hemorrhage

Gestational Diabetes

Placenta previa

Placenta Abruptia

Preeclampsia3rd Most common cause of maternal mortality world wide (12% all deaths)

May be reduced by up to 55% in women who begin 20 min of exercise 5 X per week in first trimester

Symptoms: High blood pressure and protein in the urine (due to kidney failure) after 20th week in pregnancy

Caused by autoimmune disorders, diet, lack of exercise, blood vessel problems

Risk factors: first pregnancy, twins, obesity, > 35 y/o, diabetes

Testing for Preeclampsia

Protein lab tests (urinalysis)

Weight gain greater than 2 lbs/week

BP > 140/90

Elevated liver enzymes

Swelling hands/face/feet

Decreased platelet count (less than 100,000)

Preeclampsia Monitoring

2010 Study of 50 women by Callaway and Colditz showed improvements in fasting glucose at 28 weeks and insulin at 36 weeks for those who exercised greater than 900 cal/week

2003 Study showed Magnesium sulfate to reduce risk of preeclampsia more than 50% for women and is “drug of choice” above any hypertensives or other treatment

2003 Sorensen et al found a 54% reduction in pre-eclampsia diagnosis for women who exercised vigorously in the year preceeding pregnancy and in early pregnancy.. 34% reduction for those with ANY form of physical activity that was regular, and 24% reduction for women who reported light to moderate (less than 6 METS) compared with non-exercise group

Saftlass et al (2004) suggested that women who engaged in any Leisure time physical activity regardless of caloric intake were significantly decreased their chance of getting preeclampsia

Caesarean-Section

Urinary incontinence

Bowel/bladder scar tissue symptoms

Endometriomas

Placenta previa and abruptio in subsequent pregnancies

Pain

Hypotonia & Hypertonia

Postpartum Infections

Pelvic Floor Spasticity

Pelvic and Abdominal floor Flaccidity,Levator Abnormalities

Normal DeliveryPerineal Trauma

Coccygeal Fracture

Pubic Diastasis

Neuropathy

Post Epidural Pain

Low Back Pain & Pelvic Girdle Pain

Urinary Incontinence

Postpartum Evaluation

Uterus changes in size, location, and volume

Pelvic Floor changes

Urogenital and GI Changes

Wound Healing

Superficial Nerve Entrapment at site of C-Section

Pain

Low Back & Pelvic Girdle Instability

Postpartum Cardiomyopathy1 out of every 1,300 deliveries

Mortality Rate is 25-50%

Weak heart diagnosed within fifth month post delivery

Risk Factors: obesity, alcohol, cardiac diagnosis prior to pregnancy, smoking, multiple pregnancies, undernourished

Symptoms: fatigue, increased nocturia, racing or skipping beats, SOB lying flat, swollen ankles

Complications: CHF, Embolism (Pulmonary), Arhythmias

Treatment: Hospital/ER, immunosuppressive treatment and aortic balloon, heart transplant, medications, fluid restrictions,activity limitations

Venous Air Embolism

More commonly associated with C-section

Incidence 50-95%

1% of all maternal deaths

Occurs more often with Steep Trendelenburg positions

Symptoms: Hypotension, hypoxemia, chest pain

Treatment: Change position, 100% forced O2, IV fluids, encourage fast delivery without CS

BAS ApplicationsQuality and efficiency

Visual Analysis

Video

Gait Analysis Tools

BAN Applications Special Diagnostic

TestsSLR (SN=.98; SP= .61)

ASLR (SN= .25; SP=.86)

Gaenslen’s (SN=.71; SP= .26)

FABER (SN> .82, SP>.60)

SIJ ant distraction (SN=.60;SP=.81): post compression (SN=.69; SP=.69)

Hip Scour

Anterior labral

Barriers to BAN implementation

Reliability and efficiency of sensor systems

Many sensor systems had same authors for system developers (bias)

Expensive

Accelerometers should be utilized with more than one sensor…

One accelerometer (65% accuracy)

Two accelerometers (87% accuracy)

Legal & Ethical Issues

Personal Data safety

Technology for elders may be seen as a limit to their independence (constant monitoring of symptoms that may impact social and community movement)

Future ResearchEvidence for reliability, validity, and responsiveness of wireless network body sensors must be established for each protocol

Collaborations between health care provider experts in diagnostics and rehabilitation, patients, computer and bioengineers, and wireless industry

Examination of this type of BAN system to be utilized in countries of challenged socio-economic needs and where access to health care is limited.

Thank You!“The doctor of the future will give no medicine, but will interest his patients in the care of the human frame, in diet, and in the cause and prevention of disease.” -Thomas Edison, Inventor

ReferencesFrancois KE, Foley MR. Antepartum and postpartum hemorrhage. In: Gabbe SG, Niebyl JR, Simpson JL, eds. Obstetrics - Normal and Problem Pregnancies. 5th ed. Philadelphia, Pa: Elsevier Churchill Livingstone; 2007:chap 18

Houry DE, Salhi BA. Acute complications of pregnancy. In: Marx J, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 7th ed. Philadelphia, Pa: Mosby Elsevier; 2009:chap 176

Cunningham FG, Leveno KL, Bloom SL, et al. Obstetrical hemorrhage. In: Cunningham FG, Leveno KL, Bloom SL, et al., eds. Williams Obstetrics. 23rd ed. New York, NY: McGraw-Hill: 2010:chap 35.

Rosmans C, Holtz S, & Stanton C. Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. The Lancet. 2006;368: 1516–1523.

Dumont A, de Bernis L, Bouvier-Colle MH, Breart G (2001). Caesarean section rate for maternal indication in sub-Saharan Africa: a systematic review, Lancet, 358: 1328-1333.

De Brouwere V, Dubourg D, Richard F, Van Lerberghe W (2002). Need for caesarean sections in west Africa. Lancet, 359: 974–75.

Rosmans C, Holtz S, & Stanton C (2006). Socioeconomic differentials in caesarean rates in developing countries: a retrospective analysis. The Lancet, 368: 1516–1523.