cybertherapy & rehabilitation, issue 4 (1), spring 2011

Issue 1 / 2011

PersonalizedHealth Today

and much more...

T h e O f f i c i a l V o i c e o f i A C To R

ISSN 2031 - 278

FEATURES:Wearable Health “Companions”p 16

Contact Lens with Integrated Sensorsp 30

COVER STORY:

COUNTRY FOCUS:Polandp 52

NEW! ASK THE EXPERTIlias Iakovidisp 43

Next Issue: Robert Madelin

Leading the Path to KNOWLEDGE

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1

Letter from the SecretaryGeneral and Editor-in-ChiefProfessor Dr. Brenda K. Wiederhold

Dear Reader,

In just two more years, people will access theInternet from their cell phones more often thanfrom their PCs. Now that some of the early chal-lenges such as compact-format data, data synchro-nization, and secure data transmission protocolshave been met, patients and providers are looking tocell phones as a cost-effective delivery system tomanage a variety of chronic conditions, includingmental disorders.

Mobile health is variously known as mHealth, ubiqui-tous or pervasive healthcare computing, “edge” care(care in homes, workplaces, or mobile environments),or personal health systems. To be sure, healthproviders have been using handheld technology foralmost 15 years to manage patients at nonclinicalsites. Four years ago, the European Commission con-vened a Personal Health Systems conference, whichattracted 400 participants. What is new in 2011 is themove to empower patients by putting mental healthapplications on their cell phones.

In an overview of the potential for wireless mentalhealth monitoring, Varshney (2009) proposes thatcertain mental health conditions – such as posttrau-matic stress disorder (PTSD), obsessive-compulsivedisorder, panic disorder, eating disorder, and majordepression — are particularly well suited to remotemonitoring. A context-based algorithm could beused, for example, to weight activity monitoring andsleep monitoring variables that might suggest thepossibility of PTSD.

The U.S. Army is made up of 86% males, and 68% ofsoldiers are less than 29 years of age – the profile ofthe typical smartphone user. The RAND study foundthat 14% of Operation Enduring Freedom/OperationIraqi Freedom veterans screened positive for PTSD,14% screened positive for major depression, and 19%reported a probable traumatic brain injury duringdeployment. The use of smartphones is perceived asa way to overcome the stigma attached to seekingmental healthcare for this highly mobile, computer-literate population. In addition to scheduling andreminder capabilities, smartphones are evolving intodevices capable of delivering podcasts, engagingpatients in game-like simulations, and providingautomated assessments and other evidence-basedtools. Smartphones can provide immediate self-man-agement of mild symptoms, as well as immediatetwo-way contact with support systems during crisis.

In the U.S., insurance reimbursement is the biggestbarrier to adoption, with Food & DrugAdministration regulations, liability questions, andan entrenched healthcare establishment, amongother barriers. Conversely, mHealth enablers includethe rise in the number of smartphone users, next-generation wireless chips that will make healthcaredelivery more seamless, algorithms enabling richerand more useful data sets, and the government’sinterest in wireless health. Indeed, support for wire-less mental health was originally included inPresident Obama’s healthcare plan.

Europe was ahead of the curve on mHealth, andtoday the European Union is supporting research

“A recent report summarizes: ‘[mHealth] will reduce financialstrain throughout the system (providers, payers, and patients)while promoting far better overall health. In practice, edge carewill enable better preventive care so that many patients willavoid major problems altogether.’”

into personal health systems under the SeventhFramework Programme (FP7). The U.S. is catching

up quickly, convening a Digital Health Summit atthe January 2011 International ConsumerElectronic Show. Today, there are about 5,000health-related applications for smartphones.

In both Europe and the U.S., the cost of caring foraging populations is a driver of mHealth. The totalcost of chronic diseases in the U.S. is more than$1.4 trillion. By 2014, using mHealth, public andprivate payers may save up to $6 billion.

A recent report summarizes: “This new approachto healthcare will reduce financial strain through-

out the system (providers, payers, and patients)while promoting far better overall health. In prac-

tice, edge care willenable better preventivecare so that manypatients will avoid majorproblems altogether.Patients will be far moreknowledgeable abouttheir own health status,and empowered andmotivated to maintaintheir health. All of this

should lead to greatly reduced spending while pro-viding improved patient outcomes.”

I invite C&R readers and researchers to look at thecell phone in your hand and embrace it as anextension of your arm, enabling you to begin tochange eHealth into iHealth, truly individualizedhealthcare.

“To be sure, health providers have been using hand-held technology for almost 15 years to managepatients at nonclinical sites ... What is new in 2011is the move to empower patients by putting mentalhealth applications on their cell phones ... Today,there are about 5,000 health-related applicationsfor smartphones.”

Create your own reality!Brenda Wiederhold

2

Letter from the Secretary General(continued from page 1)

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Wounds of War III: Coping withBlast-related Traumatic BrainInjury in Returning TroopsEDITED BY:Professor Dr. Brenda K. Wiederhold, Ph.D., MBA, BCIA

The post-conference book reflects the key topics

discussed in the four sections at the workshop:

First session - Characterization of TBI

Second Session - Diagnostic and Assessment

Issues Surrounding TBI

Third session - Treatment of TBI

Fourth Session - Quality of Life

WOUNDS OF WAR III: COPING WITH

BLAST-RELATED TRAUMATIC BRAIN

INJURY IN RETURNING TROOPS

On February 20-22, 2011 the NATOAdvanced Research “Wounds of War III:Coping with Blast-related Traumatic BrainInjury in Returning Troops” drew over 30eminent experts from 11 countries to dis-cuss the topic of increased TraumaticBrain Injury (TBI) in our service men andwomen.

Held in Vienna, Austria at the HotelRegina, discussion topics includedincreased TBI as a result of missions, aswell as how TBI may be prevented.Research has shown that those who haveserved in both combat missions andpeacekeeping operations are at anincreased risk for TBI. The ultimate aim ofthe workshop was critical assessment ofexisting knowledge and identification ofdirections for future actions. The co-organizers of the workshop alongsideProfessor Brenda K. Wiederhold includedProfessor Kresimir Cosic, Professor MarkD. Wiederhold and Colonel Carl Castro.

Full papers were published with IOS PressTO ORDER: [email protected]

The Interactive Media Institute9565 Waples Street, Suite 200 – San Diego, CA 92121

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Professor Brenda K. WiederholdPh.D., MBA, BCIAEditor-in-ChiefC&R MagazineBelgium

Professor Rosa M. Baños, Ph.D.University of Valencia Spain

Professor Cristina Botella, Ph.D.Universitat Jaume ISpain

Professor Stéphane Bouchard, Ph.D. Universite du Quebec en Outaouais (UQO)Canada

A.L. BrooksAalborg UniversityDenmark

Professor Paul M.G. Emmelkamp, Ph.D. University of AmsterdamThe Netherlands

Professor Luciano Gamberini, Ph.D.University of PadovaItaly

Professor Sun I. Kim, Ph.D.Hanyang UniversityKorea

Professor Dragica Kozaric-Kovacic, M.D., Ph.D.University Hospital DubravaCroatia

Professor Paul Pauli, Ph.D.University of WürzburgGermany

Professor Simon Richir, Ph.D.Arts et Metiers ParisTechFrance

Professor Giuseppe Riva, Ph.D., M.S., M.A.Istituto Auxologico ItalianoItaly

Professor Paul F.M.J. Verschure, Ph.D.Universitat Pompeu FabraSpain

Professor Mark D. Wiederhold, M.D.,Ph.D., FACPVirtual Reality Medical CenterUSA

Professor XiaoXiang Zheng, Ph.D.Zhejiang UniversityP.R. China

C&R Editorial BoardGENERAL INFORMATION

CyberTherapy & Rehabilitation Magazine

ISSN: 2031-278

GTIN-13 (EAN): 9771784993017

CyberTherapy & Rehabilitation Magazine is published quar-

terly by the Virtual Reality Medical Institute (VRMI), 64 Rue

de l'Eglise, Boite 3, 1150 Woluwe-Saint-Pierre, Belgium and

the Interactive Media Institute, 9565 Waples Street, Suite 200,

San Diego, CA 92121, U.S.A. The magazine explores the uses

of advanced technologies for therapy, training, education,

prevention, and rehabilitation. Areas of interest include,

but are not limited to, psychiatry, psychology, physical

medicine and rehabilitation, neurology, occupational ther-

apy, physical therapy, cognitive rehabilitation, neuroreha-

bilitation, oncology, obesity, eating disorders, and autism,

among many others.

PUBLISHING HOUSEVirtual Reality Medical Institute BVBA

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ADVERTISING For advertising information, rates, and specifications please

contact Virtual Reality Medical Institute, 64 Rue de l'Eglise,

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REPRINTSIndividual article reprints are available from corresponding

authors. Please contact the publisher for rates on special

orders of 100 or more.

MANUSCRIPTSSubmissions should be addressed to the C&R Managing Ed-

itor, Virtual Reality Medical Institute: [email protected].

COPYRIGHTCopyright © 2011 by Virtual Reality Medical Institute. All rights

reserved. CyberTherapy & Rehabilitation Magazine is owned

by Virtual Reality Medical Institute BVBA and published by the

Virtual Reality Medical Institute BVBA. Printed in Hungary.

With the exception of fair dealing for the purposes of re-

search or private study, or criticism or review, no part of this

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For permission to photocopy an article for internal purpos-

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The accuracy of contents in CyberTherapy & Rehabilitation

Magazine are the responsibility of the author(s) and do not

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mation presented in advertising portions of this publication.

LETTER FROM THE EDITOR-IN-CHIEFB. Wiederhold p 1

COVER STORYPersonalized Health Systems TodayM. Wiederhold, B. Wiederhold p 12

FEATURESThe MONARCA Project for Bipolar Disorder TreatmentO. Mayora Ibarra p 14

Wearable Health “Companions”L. Brown, J. Penders p 16

The INTERSTRESS ProjectG. Riva, B. Wiederhold, A. Gaggioli p 18

Personal Health Systems: The OPTIMI Project M. Alcañiz et al. p 20

EEG Systems for Personalized HealthcareA. Casson p 22

To Telehealth and BeyondN. Lovell, S. Redmond p 24

PRODUCT COMPARISON CHARTPersonalized Health Systems p 26

Contact Lens with Integrated SensorsH. Yao, I. Lähdesmäki, B. Parviz p 30

The SOCIABLE ProjectM. Alcañiz, I. Zaragozá p 32

The TBIcare ProjectM. van Gils, O. Tenovuo p 34

Healthcare in Free FallS. Redmond, N. Lovell p 36

Brain Machine Interfaces for Personalized HealthK. Oweiss p 38

Wearable Systems for Brain-body TherapyA. Tognetti et al. p 39

ASK THE EXPERTI. Iakovidis p 43

FROM WHERE WE SIT & FURTHER AFIELDG. Riva, L. Kong p 46

Autism Therapy for Children using the Robot KASPARB. Robins, K. Dautenhahn p 50

COUNTRY FOCUSPolandE. Butcher p 52

TABLE OF CONTENTS

7

Advancements in Telehealth

The use of ICT-based devices such as theTeleMedCare system, above, not only help tokeep caregivers updated on patient status andhealth conditions, as well as lessen their work-load, but also provide patients with a sense ofcontrol and empowerment since they can mon-itor their condition from their own home. Self-monitoring has been shown to be an importantfactor in improvements in health outcomes.

Moving to “Patient-centric Care”

A key trend in personalized health systems isutilizing user-friendly devices for patients,such as the imec/Holst Centre 8-ch EEG wear-able headset, above. Products using sensingtechnologies not only monitor health status,but also measure stress and other factors thatmay not be readily identifiable to the user.Increased wearability and ease-of-use contin-ue to be areas in which huge strides are beingmade, while overall, helping to improvehealthcare.

T h e O f f i c i a l V o i c e o f t h e I n t e r n a t i o n a l A s s o c i a t i o n o f C y b e r P s y c h o l o g y , T r a i n i n g & R e h a b i l i t a t i o n

International Association of CyberPsychology, Training & Rehabilitation (iACToR)

Conference Participation Report Spring 2011

8

Medicine Meets VirtualReality 18 Conference

The 18th annual Medicine Meets Virtual Re-ality (MMVR) conference was held February8-12, 2011 at the Newport Beach MarriottHotel and Spa in Newport Beach, California.

MMVR18 offered an opportunity for atten-dees to discuss their virtual reality (VR)modalities in medicine, mental health, re-habilitation, robotics, engineering, biomed-icine and education. Many mental healthproviders met to share their efforts usingVR and advanced technological approach-es in clinical and research settings.

In addition, the iACToR Military SIG and theInteractive Media Institute co-organized aone-day VR and physiology clinician train-ing workshop entitled "VR- Assisted Expo-sure Therapy in PTSD.” The American Psy-chological Association Continuing Education(APA-CE) workshop, conducted by Dr. JamesL. Spira, was very well received and aimedto introduce clinicians to the use of VR to facilitate exposure-based treatment of PTSD, including combat-related and civilian

forms of the condition. Major approaches discussed includedmaintaining maximum exposure and arousal, gradual exposure(to be used with physiological monitoring and feedback to achievesystematic desensitization) and training in attentional engage-ment and arousal control (such as stress inoculation training.)

A number of iACToR members, as well as board members fromC&R and the Journal of CyberTherapy & Rehabilitation, were inattendance during conference proceedings, and enriched themeeting with their contributions and presentations on their cur-rent lines of research.

Prof. Giuseppe Riva’s research group presented a poster titled,

“NeuroVR2 – A Free VR Platform for Assessment and Treatmentin Behavioral Health Care.” The NeuroVR2 allows users to adapt

the content of 14 pre-designed virtual environments tothe specific needs of the clinical or experimental setting.Additionally, Major Melba Stetz organized a session on"VR for Psychology's Clinical and Research Use", and Dr.Dennis Patrick Wood presented a paper titled “VR Grad-ed Exposure Therapy with Physiological Monitoring forthe Treatment of Combat Related PTSD." This study, fund-ed by the Office of Naval Research, was completed by theVirtual Reality Medical Center and the Naval Medical Cen-ter San Diego. Participants who engaged in 10 90-minute

VR sessions showed a significant reduction in the severity of theirPTSD symptoms.

Two projects currently funded by ICT for Health, European Com-mission, teamed up as well for a symposium. Members of INTER-STRESS (Interreality in the Management and Treatment of Stress-Related Disorders) and OPTIMI (Online Predictive Tools forIntervention in Mental Illness) presented their projects to confer-ence attendees. Chaired by Prof. Giuseppe Riva, the symposiumwas intended to enlighten attendees on research advances beingmade in Europe with new tools and technologies. Other mem-bers of the symposium were Prof. Rosa Banos, Prof. Cristina Botel-la, Prof. Andrea Gaggioli, and Prof. Brenda K. Wiederhold. An ab-

Dr. Jim Spira led a one-day workshop addressing “VR Assisted Exposure Therapy in PTSD.”Here, he works with a clinician to familiarize him with a VR system.

February 8-12, 2011Newport Beach, California

MMVR18 offered an opportunity for thoseattending to discuss their virtual reality (VR)modalities in medicine, mental health, re-habilitation, robotics, engineering, biomed-icine and education.


9

NATO Wounds of War IIICoping with Blast-related Traumatic Brain Injury in Returning Troops Vienna, Austria/ February 20-22, 2011

The third NATO Wounds of War Advanced Research Workshop, entitled “Cop-ing with Blast-related Traumatic Brain Injury (TBI) in Returning Troops,” washeld February 20-22, 2011 at the Hotel Regina in Vienna, Austria. The workshopwas the third in a series of successful workshops that aim to address “invisi-ble” injuries sustained as a result of both peacekeeping and combat missions,including "Wounds of War I: Lowering Suicide Risk in Returning Troops,” heldOctober 14- 17, 2007 in Südkärnten, Austria, and "Wounds of War II: Posttrau-matic Stress Disorder," held October 19- 21, 2009, also in Südkärnten, Austria.

The workshop, organized by the Virtual Reality Medical Institute (VRMI) (Bel-gium) and the Interactive Media Institute (IMI) (USA), was convened to discussTBI topics including characterization, diagnostic and assessment issues, treat-ment, including cutting-edge technologies being implemented and tested atthis time, and quality of life of those affected by TBI. The workshop drew 35top-level participants, representing 10 NATO and PfP countries.

Professor Dr. Brenda K Wiederhold, IMI and VRMI, and Professor Dr. WalterMauritz, International Neurotrauma Research Organization served as Co-or-ganizers and Professor Dr. Kresimir Cosic of the University of Zagreb, Croatia,Colonel Dr. Carl Castro of the United States Army Research and Materiel Com-mand, and Professor Dr. Mark D. Wiederhold of the Virtual Reality Medical Cen-ter, San Diego, California served on the Program Committee. Additional spon-sors included NATO, the Virtual Reality Medical Center, Social Welfare Croatia,the Austrian Worker’s Compensation Board, the United States Army MedicalResearch and Materiel Command, the Austrian Ministry of Defence and theInternational Neurotrauma Research Organization.

The fourth WoW workshop, “Pain Syndromes – From Recruitment to Return-ing Troops,” is scheduled for June 3-5, 2011 in Salzburg, Austria. A fifth work-shop will focus on Military Families and a sixth on Substance Abuse. For fur-ther information, please visit: www.interactivemediainstitute.com/conferences.

Blue Helmet Forum Austria 2010Stress Management and Peace SoldieringVienna, Austria/ October 5-7, 2010

The annual Blue Helmet Forum Austria (BHFA) took placeOctober 5-7, 2010 in Vienna, Austria. The conference, or-ganized by the Association of Austrian Peacekeepers incooperation with the Austrian Ministry of Defence, fo-cused on “Stress Management in Peacekeeping” and dis-cussed different types of stress and ways to manage stressas it relates to international peace operations.

General (ret) Günther Greindl and General Raimund Schit-tenhelm, Commandant of the National Defence Acade-my, opened the forum by addressing international par-ticipants including researchers, experts, and practitioners.Overall, issues discussed included preventative psycho-logical care; ways in which pre-deployment training canbetter teach soldiers to effectively manage stress, newtherapies to treat stress, and lasting psychological effectson the military population, as well as the civilian popu-lation.

On the topic of pre-deployment training, Dr. Brenda K.Wiederhold presented a paper on “Pre-Deployment StressInoculation Training” in which virtual reality is used toprevent or attenuate stress-related reactions soldiers faceduring deployment.

The conference series continues to promote Austria’s en-gagement in peacekeeping activities and works to pro-mote societal ideals as outlined by the United Nations. This year’s conference will be held September 21-23,2011. More information can be found at www.austrian-peacekeepers.at/content/content15.html.

Members of the symposium included Prof. Giuseppe Riva,Prof. Rosa Banos, Prof. Cristina Botella, Prof. Andrea Gaggi-

oli, and Prof. Brenda K. Wiederhold.

stract of the resulting MEDLINE-indexed paper is nowpublished and discusses INTERSTRESS, Monarca, OPTI-MI, and Psyche (all funded by ICT for Health). To viewthe abstract, please visit http://www.ncbi.nlm.nih.gov/pubmed/ 21335846.

The success of the 18th MMVR conference further af-firms the fact that VR is quickly gaining ground in manydifferent areas of research and application. C&R is proudto be a part of these developments and meetings in-volving top researchers from around the world. Formore information on the conference, please visitwww.nextmed.com.

News from iACT0R MembersOrganization grows worldwide as Special Interest Groups/Regional Chapters are established

As the official association of CyberThera-py & Rehabilitation, we will be bringing youupdated news of various special interestgroups and regional chapters of the Inter-national Association of CyberPsychology,

Training & Rehabilitation as they grow andexpand throughout the year. As the organ-ization becomes more well-established, itis further strengthened by growing num-bers from around the globe. We welcome

iACToR members, as well as our readers, tosubmit content and updates, as well as sug-gestions for new groups. You can do so byreaching the Managing Editor at [email protected].

Military Special Interest GroupSIG Leaders: Melba Stetz andDennis Wood

The Military iACToR Special InterestGroup (SIG) recently met during theMedicine Meets Virtual Reality 18Conference (MMVR) held February8-12, 2011 at the Newport BeachMarriott Hotel & Spa, NewportBeach, CA (USA) to discuss their vir-tual reality (VR) modalities in medi-cine, mental health, rehabilitation,robotics, engineering, biomedicineand education.

Additionally, in a recently completedstudy at Naval Medical Center SanDiego and Naval Hospital CampPendleton (USA), Robert N. McLay etal. investigated the effects of VR Ex-posure with Arousal Control (VRE-AC)versus Treatment As Usual (TAU) forcombat-related PTSD. Result suggeststhat VRE-AC can be a useful modali-ty in treating combat-related PTSD.

Of note, this study will be publishedin Cybertherapy, Behavior and SocialNetworking in April, 2011.

Dr. Spira and Dr. Stetz, with the help ofother VR “gurus,” plan to collaborateon a study investigating PerformanceImprovement/Quality Project at the De-partment of Psychology of the TriplerArmy Medical Center, Hawaii. This proj-ect will aim to create a "VR stand-alonestation" where clinicians and mentalhealth students can learn/re-learn tointegrate VR and biofeedback technol-ogy into their sessions.

To read about how VR therapy mayassist in the treatment of combat-re-lated PTSD and to hear an audio in-terview with Dr. Robert McLay (CDRMC USNR), please access the follow-ing web page: http://www.medpageto-day.com /MeetingCoverage/APA/20309.

Stay abreast of new topics and tech-nology by joining the Military Spe-cial Interest Group onhttp://iactor.ning.com.

Mexican iACToR ChapterInformation provided by Georgina Cardenas

The Virtual Teaching Cyberpsychology Laboratory was found-ed by Georgina Cárdenas, Ph.D., on April 23, 2001 as a Re-search, Education and Clinical Unit of the Faculty of Psychol-ogy of UNAM. The main purpose of this laboratory is to createshared participative knowledge for the incorporation of ad-vanced technologies to the virtual teaching of psychology andpsychological treatments for the solving of individual and col-lective problems.

The Virtual Teaching Cyberpsychology Laboratory has researchprojects devoted to the technological development and researchin psychology, such as the: “Development and Evaluation of Vir-tual Reality Technology Based Systems for Anxiety Disorders, the“Development and Evaluation of Expert Systems for the Teachingof Professional Competencies in Psychology” and the “OnlineTeaching of Professional Competencies for Domestic Violence In-terventions.”

One of the principal objectives of the lab is to open new researchlines devoted to technological development and research in psy-chology, focusing on solving and addressing psychological prob-lems of high social relevance. For example, the case of Posttrau-matic Stress Disorder in victims of criminal violence, and thetreatment of Complicated Grief and Depression in residents of Cd.Juarez, among others. It is also an aim of the lab to collaboratewith other groups and institutions from different countries, and tocreate collaborative interdisciplinary groups.

The lab is currently made up of 26 members including profes-sors, researchers, graduate students and undergraduate stu-dents who continue researching and using advanced technolo-gies and Virtual Reality in a variety of fields. These individualsare highly motivated in developing virtual environments andanalyzing patterns of human behavior, as well as communicat-ing and collaborating with other scientists.

Stay abreast of new topics and technology by following or joining thegorup on http://iactor.ning.com.

Student Special Interest GroupSIG Leader: Willem-Paul Brinkman

The International Association of CyberPsychology,Training & Rehabilitation’s Student Special Inter-est Group supports fellow students with their re-search and education in this area. Our membersare primarily students, but membership is also opento other iACToR members that like to help studentsto become professionals.

The group aims in connecting students and en-courages the exchange of information amongmembers that are of interest to students, dealingwith issues such as conducting research, publish-ing your work or developing a career in this area.Furthermore, the group also helps in bringingmembers in contact with the leaders of the com-munity. It promotes the interests of students ingeneral, and specifically in the association, theevents it organises or endorses.

By joining the group, you will have access to on-line material relevant for students. You will be ableto develop your international network, and havean opportunity to interact with your peers.

Become a member today by joining the StudentSpecial Interest Group on http://iactor.ning.com.

10

Cyberpsychology, Behavior, and Social Networking

Special Issue onPosttraumatic Stress Disorder

Lessons Learned from VR Sessions with Warriors with Combat-Related PTSD

Behavioral Treatment of Earthquake Survivors

PTSD Due to Motor Vehicle Accident

Therapeutic Alliance in Telepsychotherapy

Virtual Reality in Iraq

And More...

V o l u m e 1 3 , N u m b e r 1 F e b r u a r y 2 0 1 0 1 S S N : 2 1 5 2 - 2 7 1 5

Now Available Online!

Special Issue

on PTSD

Visit

www.liebertpub.com/cpb to

view the issue for free!

“Personalized Health Systems encompass an array of different eHealth tech-nologies that range from electronic health records, to body monitors andimplantable systems, all of which have helped improve healthcare, especial-ly with an aging population and prices of treatment constantly rising.”


12

Personalized HealthSystems Today

By Mark D. Wiederhold & Brenda K. Wiederhold

COVER STORY

Innovations in technology have aided health-care throughout the world in diverse wayssuch as developing new methods for pre-vention, rehabilitation or surgery, and havealleviated some of the pressures put onhealthcare systems to treat a rapidly increas-ing population. eHeath especially has grownthroughout the years and is a main area ofstudy for many trying to make healthcaremore efficient and less expensive for bothpatients and healthcare providers. The de-velopment of Information and Communi-cation Technologies (ICT), which usestelecommunications to transfer informationand communicate easier and faster thanever before, has allowed eHealth to branchout into personalized methods of treatmentthat are both cost efficient and more indi-vidually designed to patients allowing formore accurate care and independence. Per-sonalized Health Systems encompass an ar-ray of different eHealth technologies thatrange from electronic health records, to bodymonitors and implantable systems, all ofwhich have helped improve healthcare, es-pecially with an aging population and pricesof treatment constantly rising.

Electronic Health Records

Electronic health records have slowly edgedtheir way into the medical system, replac-

ing paper documentation and all forms ofadministrative information. Electronichealth records make data storage more or-ganized and help to cut down on time andspace needed to collate and file paper doc-uments. It also makes transporting recordsless time consuming, as well as allows formultiple copies to be created more effi-ciently and is less expensive than duplicat-ing paper records. Furthermore, electron-ic health records would also give patientsbetter access to their own health informa-tion because the records can be sent di-rectly over the Internet. Administrativetasks would also be made easier, sincescheduling and follow-ups could be easilyupdated on a computer database, andwould allow doctors to order prescriptions,tests, and lab results with the click of a but-ton. Although electronic health record pro-grams have been around for the past fewdecades, many healthcare providers are re-luctant to adopt the new system. Unfamil-iar with how the system works, manywould require technical training in orderto use the programs, and maintenance andsystem incompatibility have turned someaway from using electronic health recordsystems. Another important issue circu-lating is the concern for privacy. With every-thing digitalized, unauthorized access ofmedical records is harder to manage and

could threaten patient privacy. However,despite these potential setbacks, electron-ic health records provide a more cost andspace efficient alternative to paper recordsthat is growing in popularity, and makingshared information more accessible.

Medical professionals and researchers arealso striving to create a collection of all datapertaining to the human body on a largeonline database called the Virtual Physio-logical Human (VPH). The frameworkwould be all encompassing, not separat-ing information by discipline or regions ofthe body, and would provide intersectingstudies of both patient-specific and gen-eral data. This will be used a reference toolthat would help provide the most compre-hensive and thorough treatment possible,and will grow along with the medical field.

Wearables and Remote Monitoring

ICT has also paved the way for more con-venient methods of monitoring patientsoutside medical facilities by improvingmedical wearable devices. Medical wear-ables can be as simple as a bracelet imbed-ded with a microchip that contains a per-son’s medical information, to morecomplex tools and devices like clothing andbio-medical sensors that constantly meas-


ure vital signs such as temperature, heartrate, and glucose levels. Patient monitor-ing through wearable body sensors previ-ously relied on devices that collected dataoff-line. However, ICT technologies now al-low for data to be collected wirelessly. Per-sonal and body area networks (PAN/BAN)bypass uncomfortable wires that accom-panied traditional body sensors, and trans-mit data wirelessly to a medical profile inreal-time, storing the data in one place.These wireless intelligent sensor networks(WISE), have given doctors the ability tomonitor patients from remote locations,cutting down on related costs and time fordoctor’s visits and hospitalization, whilegiving patients more freedom to live inde-pendently, despite having an otherwise de-bilitating medical condition. Remote mon-itoring can be used for a number ofdifferent conditions ranging from highblood pressure, diabetes, and heart attack,to keeping an eye on post-surgical patientsand the elderly.

MyHeart, a European collaborative projectfunded by the European Commission, is inthe process of developing a monitoring sys-tem for cardiovascular diseases (CVD). Bil-lions of dollars have already been spent tohelp treat CVD, a leading cause of death inthe west, and MyHeart strives to cut coststhrough preventative monitoring. Early de-tection is key in fighting CVD. MyHeartprovides patients constant monitoringthrough the use of pressure sensors in tex-tiles, for example, on bed linens to moni-tor breathing habits while users are sleep-ing, and t-shirts equipped with ECGelectrodes, called intelligent biomedicalclothes. MyHeart gives a personalized read-ing of patients’ condition, allowing for treat-ment aimed at helping patients’ specificcondition to be improved, and will helpmake diagnoses and prevention easier.Feedback devices linked to the sensors willalso give patients the power to self-moni-tor, as well as allow healthcare profession-als to monitor patients remotely, makingtreatment more affordable and efficient.

Some monitoring devices, like the EU-

funded REACTION which measures glu-cose and insulin levels of diabetes patients,will trigger an emergency alarm alertinga physician when vitals reach a dangerous

level for the patient, ensuring immediatecare. This allows patients to live more com-fortably knowing that their condition isconstantly being watched by their doctor.Treatment is further enhanced since a pa-tient’s medical profile is always beingrecorded and updated, allowing physiciansto devise a more individualized treatmentplan for specific conditions.

Mental Healthcare

Mental healthcare sectors have also ben-efited from improved remote monitoringsystems and medical wearable technolo-gy. Bio-medical sensors can be designedto measure vitals linked to depression, andalso can be designed to monitor eatinghabits, daily activities, and sleep habits,like the MONARCA project (MONitoring,treAtment and pRediCtion of bipolAr dis-order episodes), that help to regulate andtreat bipolar disorders. Others utilize Vir-tual Reality (VR) technologies to help treatpsychological disorders. The EU-fundedproject INTERSTRESS (Interreality in theManagement and Treatment of Stress-Re-lated Disorders), utilizes Interreality (a com-bination of VR and monitoring systems)to help assess and control psychologicalstress. INTERSTRESS monitors patients’emotional and physical activity with bio-medical sensors while immersed in a vir-tual world. The goal is that real life behav-ior and experiences in the virtual worldwill influence each other so that over timethe patient will learn to cope with stressusing what is learned in the virtual envi-ronment. It can be used in a clinical set-

ting along with an immersive VR world,and also at home or on-the-go throughmobile phones and the Internet, allowingfor more immediate care.

Implantable systems and the Future of ICT

One of the next steps in ICT is developingimplantable systems capable of wireless-ly transmitting data. Current implantablemedical devices are able to monitor andtreat conditions, like the Implantable Car-dioverter Defibrillator (ICD) which detectsheart arrhythmias and sends low to highelectrical impulses to the heart when nec-essary to restore a normal heart rhythm.However, these systems are limited in theirmonitoring capabilities. ICT systems willallow medical professionals to remotelymonitor a patient’s condition, as well ascontrol the device itself. The P.CÉZANNEproject is in the process of producing animplantable nano-sensor device that con-stantly monitors blood glucose levels indiabetes patients and stores the datathrough wireless transmission to a mobiledevice. It will also be capable of regulat-ing glucose through an insulin pumplinked to the device, releasing insulin intothe body when needed.

The P.CÉZANNE project is only the startof technologies of this nature and futureprojects will continue to seek ways to in-crease patient autonomy so that they canlive uninhibited by medical conditions.

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COVER STORY

[ ]Mark D. Wiederhold, M.D., Ph.D., FACPVirtual Reality Medical CenterSan Diego, [email protected]

Brenda K. Wiederhold, Ph.D., MBA, BCIAVirtual Reality Medical [email protected]

“... future projects will contin-ue to seek ways to increasepatient autonomy so thatthey can live uninhibited bymedical conditions.”

Bipolar disorder, also known as Manic-De-pressive illness, is the sixth leading causeof disability in the world according to theWorld Health Organization. Statistics showthat people affected by bipolar disorderlose, on average, 13.1 years of their pro-ductive life as a consequence of the illness.Moreover, Unipolar major depression isconsidered the leading cause of disabilityworldwide with 43 years lost in terms ofproductivity. Therefore, there is a clear needto manage and reduce the negative im-pact that these diseases have on social andeconomic spheres.

Bipolar disorder is diagnosed in around 1%of the European population, 2.6% of thepopulation in the U.S., and at least one al-ternate manic-depressive episode occursin around 10% of the world population dur-ing their lifetime.

For these reasons, the European Commis-sion decided to finance research effortstargeted at supporting therapy and self-management of people suffering frombipolar disorder.

An example of this is the recently fundedEU project MONARCA (MONitoring, treAt-

ment and pRediCtion of bipolAr disorderepisodes) coordinated by CREATE-NET Re-search Center with the collaboration of sev-eral international partners (EC Funding ofnear 4 Million Euro). MONARCA is thor-oughly investigating aspects of bipolar dis-order by adopting a holistic approach toassessment, treatment and self-manage-

ment of the disease. The project focuseson objective assessment and prediction ofbipolar disorder episodes and aims to fur-ther advance the discovery of new mark-ers for this disease.

The project utilizes state-of-the-artmethodologies for treating Bipolar Disor-


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MONARCA: An InnovativeApproach to BipolarDisorder Treatment

By Oscar Mayora Ibarra

Those suffering from bipolar disorder lose an average of 13.1 years of their pro-ductive life. The MONARCA project employs cutting-edge technology to improvemethods for assessment, treatment and self-management using such compo-nents as an activity monitor worn on the wrist and a sensor-enabled mobilephone. The project’s innovative approach is discussed.

Figure 1:MONARCA Approach.

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COVER STORY


der based on pharmacological, psychother-apeutic methods and clinical scales (e.g.BRAMS, HAMD, self assessments); devel-oping and validating a multi-parametric,closed-loop approach to improve the treat-ment, management, and self-treatment ofbipolar disorder disease.

MONARCA is an innovative system, whichconsists of five main components – a sen-sor-enabled mobile phone, a wrist-worn ac-tivity monitor, a novel sock integrated-phys-iological sensor (GSR, pulse), a stationaryEEG system for periodic measurements anda home gateway. MONARCA will combineGPS location traces, physical motion infor-mation, and recognition of complex activ-ities (eating habits, household activity,amount and quality of sleep) into a contin-uously updated behavioral profile that willbe provided to doctors in a meaningful wayto support treatment. The informationbased on sensing technologies will be used

as an objective basis for discovering trendsand predicting episodes of bipolar disorder.

In this manner, the patient's medicalrecord will correspond more accuratelywith the patient’s condition and medicalstaff can elaborate their diagnosis basednot only on self-reported experiences bythe patient, but also on objectively meas-ured information sourced from the phys-ical and physiological sensors.

The MONARCA system includes a closed-loop approach between patients and med-ical staff realized through purpose-built in-terfaces. On one hand, people affected bybipolar disorder will be aided by mecha-nisms of self-assessment, provision of warn-

ings and risk profiles through persuasiveinteraction and coaching to support self-treatment. On the other hand, the medicalstaff will have access to interfaces for in-

terpreting patient data, therapy assessment,medication planning and scheduling visitstools, developed by the project (see Fig. 1).

In order to become a useful tool for pa-tients and doctors, MONARCA’s researcheffort is based on close collaboration withtwo hospitals who are partners of the proj-ect, namely Psychiatric Center Rigshospi-talet (Denmark) and Psychiatric State Hos-pital of Tirol (Austria), allowing patients anddoctors to be involved from the early stagesof the project.

In this way, patients and therapists can in-teract with researchers and provide theirfeedback and requirements about usabili-ty and interaction with the system in order

to maximize system adoption and give pa-tients an active role in the decision-makingand self-management of their disease. Themain contributions of MONARCA beyondstate-of-the-art of management of BipolarDisorder disease are shown in Table 1.

Overall, the expected results of the MONAR-CA project include:

• Accurate assessment of bipolar disor-der episodes through objective monitor-ing

• Prevention of crisis episodes throughevent prediction algorithms

• Identification of main and eventual-ly new markers for diagnosis and treatmentof bipolar disorder

• Support caregivers for handling treat-ment and risk situations

• Improve patients’ self-managementof the disease

• Positively impact in reduction ofhealthcare costs

• System validation through dedicatedtrials in two European countries

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[ ]Oscar Mayora Ibarra, [email protected]://www.monarca-project.eu/

Table 1: Comparison of State-of-the-Art Approaches vs. the MONARCA Approach

State-of-the-Art Approach MONARCA Approach

Assessment based on self-reported experiences typically after crisis (intrinsically subjective data)

Assessment based on objective, measurable data

Sporadic assessment through interviewsContinuous state assessment through

multi-parametric monitoring

Difficulty to assess trends in the shortterm (implies actions only aftermanic/depressive episodes)

Timely warnings on “risky” trends(Prevention of crisis)

Low adherence for self-management of the disease

Increase awareness through self- monitor-ing and timely personalized coaching

“MONARCA will combine GPS location traces, physicalmotion information, and recognition of complex activities... into a continuously updated behavioral profile that will beprovided to doctors in a meaningful way to support treat-ment. The information based on sensing technologies willbe used as an objective basis for discovering trends and pre-dicting episodes of bipolar disorder.”

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Wearable Health“Companions”“Key trends [in healthcare] include the evolution from disease centric to patient

centric care, the delocalization of care from hospitals to home, and a focus on

prevention rather than cure. This paradigm shift calls for new technologies to

enable ubiquitous personal health. Body Area Networks play an important role in

enabling this change by providing people with wireless wearable solutions ideal

for personal health and lifestyle monitoring.”

By Linsdsay Brown & Julien Penders

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Figure 1:mec/Holst Centre 8-ch EEG headset.

Healthcare systems are changing in response to newdemographic factors including an aging society, increas-ing number of chronic diseases and a growing interestof individuals in managing their own health. Key trendsinclude the evolution from disease centric to patientcentric care, the delocalization of care from hospitalsto home, and a focus on prevention rather than cure.This paradigm shift calls for new technologies to en-able ubiquitous personal health. Body Area Networksplay an important role in enabling this change by pro-viding people with wireless wearable solutions ideal forpersonal health and lifestyle monitoring.

Using commercially available cardiac telemetry systemssuch as the Corventis NUVANT system, patients' ECGcan be continuously remotely monitored, with any ad-verse events being recorded and a physician notifiedfor immediate care. These systems enable long-termpatient monitoring out of the hospital environment,resulting in a higher quality of life for the patient.

Towards more assistive technologies, brain computerinterfaces have taken a step further beyond simply mon-itoring and provide integrative functions for the pa-tient. Today’s brain computer interfaces can interpretcommands such as yes/no, and control machine re-sponse through changes in the level of concentration.Companies such as Emotiv and Neurosky exploit thesame principle for improving the gaming experience.

In an effort to take EEG to the home en-vironment, imec reported a wearableEEG headset (see Fig. 1) integrating dryelectrodes. The EEG headset electronicshave been optimized to cope with thespecific challenges associated with dryelectrodes, such as very high and vary-ing input impedance. Optimized, ultra-low-power electronics achieve over threedays autonomy while wirelessly record-ing brain-waves.

Body area network technology is not lim-ited to providing health monitoring andassistive functions. Research on cogni-tion and information processing showsthat physiological activity contains muchmore information than a physiologicalstate or mental choice. Tapping into thisinformation enables personal health de-vices to go beyond merely measuring ac-tivity and become health companions.For example, combining measurementsof sleep with external factors such as caf-feine intake, the My Zeo sleep coachingsystem allows users to monitor and im-prove their quality of sleep, in much thesame way a person improves their fit-ness by exercising. The My Zeo systemalso provides interpretative functions in

real time that enable the user to be wok-en up "smartly." Using a different com-bination of sensors, a stress monitor maymeasure the physiological state relatedto stress and emotions. Employed ap-propriately, devices such as this can beused in many applications where stressand emotions influence actions andchoices. For example, a stress monitorcan be used to provide biofeedback onstress levels, enabling the user to main-tain appropriate stress levels. Anotherexample is a responsive photo frame thatreflects the user’s level of arousal in realtime using physiological measurementsfrom wearable body area network sen-sors (see Fig. 2).

While providing excellent wearability andease-of-use, often today's devices arefaced with making a trade-off betweenthe overall wearability and ease-of-useof the system with the quality and accu-racy of the signals and overall system.Current dry-electrode technology allowssignals to be measured accurately at rest;however, challenges remain in their useduring movement. Developing tech-niques for reducing motion artifact willenhance the robustness to motion arti-

fact and thus overall accuracy during dai-ly life activities. Similarly, often compli-cated algorithms are used in the inter-pretation of information, requiringhigh-computing power supplied only bya desk-top based device. Developing ca-pabilities to process and integrate infor-mation at the sensor will enable localfeedback to be provided directly by thewearable device. Further, today's bodyarea network devices are still limited toeasy-to-measure signals such as ECG andskin conductance. Novel sensing tech-nologies are needed to reliably measuremore complex parameters such as chem-ical compounds and hormones, enablinggreater insight into the physiological ac-tivity and condition. While these chal-lenges seem trivial, they are made morecomplicated by the need to make theseadvancements in a way that further re-duces power consumption beyond cur-rent levels. By reducing overall consump-tion, the autonomy of the wearablesensors is greatly increased, ensuringminimal maintenance by the user. Andfinally, while wearable today, future im-provements in device integration andminiaturization combined with theadded intelligence and reduction of pow-er consumption, will enable the wearablesensors to become truly ubiquitous.

Imec’s Body Area Network research pro-gram addresses these key technologychallenges with research focused on mi-cro-power generation and storage, ultra-low-power radios, ultra-low-power DSPs,ultra-low-power sensor technologies andadvanced electronic integration. The ul-timate target is a wearable device thatcan be used at home, in the office, in thecar, anywhere, providing functions thatenhance the users' quality of life inhealth and/or lifestyle applications. Thatwill become your health companion.

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Figure 2: The emotionally-responsive photoframe changes the intensity of the light accord-ing to the level of stress detected through wire-less physiological sensors worn by the user. Whenhighly stressed, the light intensity causes theuser to look at the photo frame and at the pho-to of their family/loved ones. This will enablethem to relax and reduce the stress intensity, inturn lowering the intensity of the light.Images credit: imec/Holst Centre

[ ]Lindsay Brown, BSc/BEngJulien Penders, MScHolst Centre/imec the NetherlandsThe Netherlands

[email protected], www.imec.be

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Interstress Project:The Use of Advanced Technologies for

Assessing and Treating Psychological Stress“What if lowering your stress level was as easy and as much fun as playing avideo game? What if all of the work was automated for you, with reminderson your mobile phone? What if the system that achieved this was so smart itchanged the program the second you changed your behavior?”

By Giuseppe Riva, Brenda K. Wiederhold & Andrea Gaggioli

What if lowering your stress level was as easyand as much fun as playing a video game?What if all of the work was automated foryou, with reminders on your mobile phone?What if the system that achieved this was sosmart it changed the program the secondyou changed your behavior?

This is the vision we used to outline a newproject funded by ICT for Health, EuropeanCommission. Called Interreality in the Man-agement and Treatment of Stress-RelatedDisorders, or INTERSTRESS for short, theproject aims to design, develop, and testan advanced ICT-based solution for the as-sessment and treatment of psychologicalstress.

“Psychological stress” occurs when an indi-vidual perceives that environmental de-mands tax or exceed his or her adaptive ca-pacity. According to the Cochrane Databaseof Systematic Reviews the best validatedapproach covering both stress managementand stress treatment is the Cognitive Be-havioral (CBT) approach. Typically, this ap-proach may include both individual andstructured group interventions (10 to 15sessions) interwoven with didactics. It in-cludes in-session didactic material and ex-periential exercises and out-of-session as-signments (practicing relaxation exercises

and monitoring stress responses). The in-tervention focuses on:

• Learning to cope more effectively withdaily stressors (psychological stress) or

traumatic events (post traumatic stressdisorder)

• Optimizing one's use of personal and so-cial resources

Figure 1: Thetechnology usedby the Interstressproject.

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CBT has undergone a very large number oftrials in research contexts. However, it hasbeen less efficacious in clinical contexts andit has become obvious that CBT has somefailings when applied in general practice.

INTERSTRESS aims to design, develop andtest an advanced ICT-based solution for theassessment and treatment of psychologicalstress that is able to address three criticallimitations of CBT:

• The therapist is less relevant than the spe-cific protocol used.

• The protocol is not customized to the spe-cific characteristics of the patient.• The focus of the therapy is more on thetop-down model of change (from cognitionsto emotions) than on the bottom-up (fromemotions to cognitions).

To reach this goal the project will use a to-tally new paradigm for e-health – Interreal-ity – that integrates assessment and treat-ment within a hybrid environment, bridgingphysical and virtual worlds. Our claim is thatbridging virtual experiences – fully con-trolled by the therapist, used to learn cop-

ing skills and emotional regulation – withreal experiences allows both the identifica-tion of any critical stressors and the assess-ment of what has been learned by using ad-vanced technologies (virtual worlds,advanced sensors and PDA/mobile phones).We believe this is the best way to addressthe above limitations.

These devices are integrated around twosubsystems (see Fig. 1) – the Clinical Plat-form (inpatient treatment, fully controlledby the therapist) and the Personal MobilePlatform (real world support, available to thepatient and connected to the therapist) –that will be able to provide:

• Objective and quantitative assessment ofsymptoms using biosensors and behavioralanalysis;

• Decision support for treatment planningthrough data fusion and detection algo-rithms, and provision of warnings and mo-tivating feedback to improve complianceand long-term outcome.

By creating a bridge between virtual and realworlds, Interreality allows a full-time closed-

loop approach actually missing in currentapproaches to the assessment and treat-ment of psychological stress (see Fig. 2):

• The assessment is conducted continuous-ly throughout the virtual and real experi-ences; it enables tracking of the individual’spsycho-physiological status over time in thecontext of a realistic task challenge.

• The information is constantly used to im-prove both the appraisal and the coping skillsof the patient and creates a conditioned as-sociation between effective performancestate and task execution behaviors.

[ ]

Figure 2: The clinical advantages of the Interreality approach.

Giuseppe Riva, Ph.D.Andrea Gaggioli, Ph.D.Istituto Auxlogico ItalianoItaly

Brenda K. Wiederhold, Ph.D.,MBA, BCIAVirtual Reality Medical InstituteBelgium

[email protected]

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Personal Health Systems:The OPTIMI Project “OPTIMI tries to determine the continuous effect of stress on the individual bystudying patterns of behavior over a longer period in order to predict whetherthe user is at risk for depression. If so, it will be able to provide an interventionprogram to reduce stress levels and the consequent risk of depression.”

By Mariano Alcañiz et al.

Currently, depression and stress-relateddisorders are the most common mentalillnesses and the prevention of depressionand suicide is one of the five key pointsin the European Pact on Mental Healthand wellbeing. Furthermore, depressionis the leading cause of disability and thefourth leading contributor to the globalburden of disease. Depression and suicideare major public health challenges, withroots across all sectors of society. Depres-sion is very prevalent, affecting 13% of Eu-ropeans during their lifetime, with highlevels of suffering for individuals and fam-ilies, as well as high costs due to loss ofproductivity and healthcare. Depressionreduces productivity due to increases insick leaves and disability pensions.

OPTIMI is a European Project funded bythe European Union's 7th Framework Pro-gramme Personal Health Systems - Men-tal Health - Collaborative Project. The co-ordination of the program is led by EverisSpain SL and the OPTIMI web page is:http://optimiproject.eu/

OPTIMI tries to determine the continuouseffect of stress on the individual by study-ing patterns of behavior over a longer peri-od in order to predict whether the user is atrisk for depression. If so, it will be able to pro-vide an intervention program to reducestress levels and the consequent risk of de-

pression. The OPTIMI project is based on PersonalHealth Systems (PHS), a new and fast grow-ing concept that has become more widelyused over the past few years. The conceptfocuses on the individualization of preven-tion, treatment and wellbeing proceduresfor patients available through the health-care system. In general, PHS are expectedto contribute to the following major needs:(a) The need for ubiquitous, unobtrusive,pervasive bio-data acquisition, processing,management and use for medical decisionsupport, (b) The need for the combinationof multilevel medical/psychological infor-mation as well as environmental informa-tion in order to promote the individualiza-tion of healthcare, (c) The need to increasethe quality of health care delivery throughrigorous biofeedback mechanisms andthus, improve patient safety.

Moreover, PHS assist people in the provi-sion of continuous, quality controlled, andpersonalized health services to empowerindividuals regardless of location. They canconsist of: a) Ambient and/or body devices(wearable, portable or implantable), whichacquire, monitor and communicate phys-iological parameters and other health-re-lated factors of an individual (e.g., vital bodysigns, biochemical markers, activity, emo-tional and social state, environment); b) In-telligent processing of the acquired infor-

mation and coupling of it with expert bio-medical knowledge to derive importantnew insights about an individual’s healthstatus; c) Active feedback based on suchnew insights, either from health profession-als or directly from the devices to the indi-viduals, assisting in diagnosis, treatmentand rehabilitation, as well as in disease pre-vention and lifestyle management.

All these features are applicable to the OP-TIMI project. There is also a growing trendin psychological research to use ecologicalmomentary assessments (EMA) that canprompt the subjects on a periodic basis torate and give answers concerning differentparameters. This approach is followed byOPTIMI since various measurements areconsistently monitored.

Currently, we have pharmacology and evi-dence-based psychological treatments (EBT)for depression and stress-related disorders.Nevertheless, we have to point out that lessthan 50% of patients receive adequate treat-ment. The main reasons are cost and thetime required for treatment, the lack of well-prepared professionals, the fact that manypatients do not decide to seek help, and theprovision of mental healthcare is generallyless than adequate in terms of accessibili-ty and quality. Regarding these worrying fac-tors, the OPTIMI project is born with theaim to develop new strategies to help those

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people affected by depression and stress,and more importantly, given the near expo-nential increment in the number of suffer-ers, to try to develop better tools for theidentification of subjects that are at risk inorder to design effective preventive pro-grams.

Goals of OPTIMI

OPTIMI approach: an important issue inthe onset of depression and stress-relateddisorders is the individual’s ability to copewith stress on a psychological and a physi-ological level. Some individuals are extreme-ly resilient, but others find it difficult tocope. OPTIMI will thus attempt to predictthe onset of illness by monitoring moodstates, coping behavior and changes instress-related physiological variables (e.g.heart rate, cortisol, sleep, etc.).

Based on these premises, OPTIMI has beencreated with two goals in mind: first, thedevelopment of new tools to monitor cop-ing behavior in individuals exposed to highlevels of stress; second, the developmentof online interventions to improve this be-havior and reduce the incidence of depres-sion. The emphasis in this project is to de-velop tools that will lead to prevention andidentification of illness in support of CBTand CCBT treatments. In other words, OP-TIMI is focused on the prediction and pre-vention of depression.

OPTIMI Trials

To achieve its first goal, OPTIMI will devel-op technology-based tools to monitor thephysiological state and the cognitive, mo-tor and verbal behavior of high-risk individ-uals over an extended period of time andto detect changes associated with stress,poor coping skills and depression.

A series of “calibration trials” will allow theproject to test a broad range of technolo-gies. These will include wearable EEG andECG sensors to detect subjects’ physiolog-ical and cognitive state, accelerometers tocharacterize their physical activity, and voiceanalysis to detect signs of depression. Theseautomated measurements will be comple-mented with electronic diaries, in which

subjects report their own behaviors and thestressful situations to which they are ex-posed. All participants will be regularly as-sessed by a psychologist who will use stan-dardized instruments to detect stress, poorcoping skills and depression. A few will alsobe asked to wear implanted devices to testlevels of cortisol in the blood, an objectivephysiological correlate of stress. The proj-ect will use machine learning to identifypatterns in the behavioral and physiologi-cal data that predict findings from the psy-chologist and the cortisol measurements.

To achieve its second goal, OPTIMI willadapt two existing systems already used toprovide online CBT treatment for mentaldisorders. The project tests the treatmentsystems in “intervention trials” targetingindividuals at high risk of exposure tochronic or acute stress. Examples includepersons with personal responsibility for thelong term care of elderly or disabled pa-tients, individuals (especially unemployedindividuals) in situations of acute financialstress, and students preparing for impor-tant examinations.

OPTIMI Contributions

The final OPTIMI monitoring system willconsist of the subset of tools that provesuseful for the detection of significantchanges and are acceptable to users, taking

into account ergonomics and usability.OPTIMI’s tools are meant to obtain relevantinformation in a constant and systematicway, and apart from providing consistentfeedback to the users about their currentsituation regarding coping, mood, andstress, the feedback provided by the systemis one of the core aspects in the manage-ment and prevention of depressive symp-toms.

In a preventative role, OPTIMI tools, com-bined with CBT techniques, provide feed-back to the user when the system can de-tect a combination of stress and a periodof negative behavioral response. On-go-ing monitoring with the OPTIMI tools willmake it possible to assess the effective-ness of treatment and to optimize thetreatment cycle.

[ ]

Figure 1: Screens illustrating some aspects of the Home PC application developed forthe OPTIMI project: voice analysis, EEG and self-reporting examples.

Mariano Alcañiz , Ph.D.Irene Zaragozá, MScBeatriz Rey, Ph.D.Universidad Politécnica de ValenciaCristina Botella, Ph.D.Inés Moragrega, Ph.D.Universitat Jaume I Rosa Baños, Ph.D.Universitat de Valencia Spain

[email protected]

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Creating PersonalizedEEG Systems forPersonalized HealthCareThe electroencephalogram, or EEG, works similarly to the ECG but recordselectrical signals from the brain, making it ideal to track changes that mighthelp to predict seizures, among other uses. Here, the author discusses thebenefits of implementing personalized EEG systems that are miniaturizedand user friendly, while providing a high level of accuracy.

By Alexander J. Casson

The increasing global population and increas-ing average age in many countries is drivinga change towards providing personalizedhealthcare. In turn, this change is driving thedevelopment of highly miniaturized, wear-able sensors that can be placed on the bodyto monitor a variety of vital signs. For exam-ple, it is common for even amateur runnersto wear a heart rate (electrocardiogram, ECG)monitor while training. These devices allowthe runner to better focus their training forimprovement, and moreover, allow them tomonitor their own heart and health so thatthey can focus on living a healthy lifestyle. Interms of providing personalized healthcare,there is even a heart rate monitor extensionavailable for the Texas Instruments eZ430-Chronos programmable watch. This is a wire-less development platform incorporatingTexas Instruments’ low power microcontrollerand transceiver components, and keen userscan use this to design, program and cus-tomize their own personal heart rate systems.

The electroencephalogram, or EEG, is in prin-ciple exactly the same as the ECG but withelectrodes placed on the head to record theelectrical signals that arise from the brainrather than the ones which arise from the

heart and are recorded from the chest. Inpractice, however, the EEG is much more dif-ficult to record than the ECG. This is due toa variety of reasons – EEG signals are muchsmaller than ECG signals and as a result,more sensitive and noise-free equipment isrequired; more electrodes are usually re-quired; there is generally more hair on thehead than on the chest making the elec-trodes more difficult to connect correctly;and moreover, the head is less physically and

visually accessible than the chest, and so asingle person cannot easily set up a systemon themselves (see Fig. 1). Whilst some ofthese are fundamental restrictions, hugeprogress towards realizing personalized EEGsystems has nevertheless been made in re-cent years. The emotiv EPOC and CamntechActiwave are two examples of commercial-ly available highly miniaturized units, andthere are many more examples too numer-ous to discuss here.

In addition, research institutes around theworld are tackling the issues highlightedabove to create truly wearable EEG systems.These will require mitigating, or devising tech-niques to tolerate, the electrode attachmentissues. The total system power consumptionmust also be reduced. For user acceptabilitydecreased power consumption means thatbattery changing and charging can becomea thing of the past, making the devices eas-ier to use. They just turn on and work. For

social acceptability, decreased power con-sumption means that the EEG unit can besmaller, more discrete and more easily toler-ated (see Fig. 2). To create these highly minia-turized systems the problems highlightedabove must be overcome, requiring innova-tions at the system design, electronic designand mechanical design levels. However, to re-alize truly wearable systems, innovations atthe medical, application and personalizationlevels are also essential.

“The aim is to create application-personalized wear-able systems that utilize the medical application toensure a robust and useful performance.”

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In many medical applications which use theEEG at present, such as epilepsy diagnosisand sleep disorder diagnosis, diagnostic pat-terns in the EEG are identified by eye by ahighly trained physician. This isn’t practicalfor future wearable systems where everlonger recordings are generated from a larg-er number of users. Instead, automated, real-time, signal analysis is mandatory, althoughthis introduces new challenges and neces-sitates application-personalization in the de-sign of future EEG systems.

As an example, research into automatedseizure detection algorithms has been goingon for more than forty years. Unfortunately,despite the huge increases in computation-al power available during that time, a defin-itive, clinically accepted procedure has yet toemerge. No algorithm has perfect accuracy.The key challenge in creating truly wearablesystems is not just in implementing seizuredetection algorithms in very low power con-sumption circuits to stay within the limitshighlighted above, but also in devising appli-cations and situations where the perform-

ance of the EEG system is robust and reliable,despite the fact that no algorithm is perfect.

Expanding on the seizure detection exam-ple, false detections inevitably mean thatautomated algorithms integrated into minia-turized EEG systems cannot be used to pro-duce a fully accurate and reliable diary ofseizure activity. This does not mean thatsuch systems are of no benefit, just that adifferent application must be pursued. Thedetection algorithm could be used to high-light sections of data that are of potentialinterest, decreasing the analysis time for atrained physician even when some false de-tections are present; or algorithms can beused to decrease the average power con-sumption of the EEG system by turningparts of the system off when no interestingactivity is present. The longer monitoringenabled could potentially detect previouslyunknown phenomena which would impactboth diagnosis and treatment decisions.

Thus, realizing truly wearable EEG systemsalso relies on realizing personalized EEG

systems, tailored for the particular medicalsituation at hand. For ECG monitoring userpersonalization is already becoming avail-able. The EEG equivalent is inevitably moredifficult, but at Imperial College in Londonwe are continuing the required researchinto system, algorithm, and circuit design.The aim is to create application-personal-ized wearable systems that utilize the med-ical application to ensure that robust anduseful performance is maintained, despitethe fact that the algorithm performancecannot be perfect. In addition to address-ing the electronic and mechanical issues,this focus on the application aim and ap-plication-personalization is essential as wemove from highly miniaturized to trulywearable devices.

Alexander Casson, Ph. D.Imperial College [email protected]

Figure 1 (right): Setup of a standard EEG recording. The EEG isgenerally much more difficult to record than the ECG and hencefuture systems require innovations on a number of fronts. Forexample, as the head is not visible and electrodes must makecontact with the scalp through the hair a trained second personis required to setup the system. Photo: Neville Miles.

Figure 2 (bottom): The scale required for future truly wearableEEG systems: a standard recording electrode, a large coin cell bat-tery, unpackaged electronics and a British one pence piece forscale. Ideally the recording electrode would be the single largestcomponent present. Photo: Eduardo Aguilar-Pelaez.

[ ]

24


In developed countries, chronic disease nowaccounts for nearly 80% of healthcare ex-penditure and nearly an equivalent percent-age of disease-related deaths. The burdenof chronic disease (often, but certainly notexclusively, associated with aging) includesasthma, hypertension, diabetes, congestiveheart failure (CHF) and chronic obstructivepulmonary disease (COPD). Over the pasthalf century there has been an epidemio-logical shift in disease burden from acuteto chronic diseases that has rendered acutecare models of health service delivery inad-equate to address population health needs.

In response to these changes in disease de-mographics and the economic imperativescaused by an aging population, service de-livery models are shifting their focus fromepisodic care to continuity of care, from in-stitutional care to community and home-based care, and from disease treatment todisease prevention.

To support this change of focus, informa-tion and communications technology (ICT)infrastructure is required to facilitate sharedservices such as virtual health networks andelectronic health records, knowledge man-agement (care rules and protocols, sched-uling, information directories), as well asconsumer-based health education, demo-graphic data, clinical signs monitoring andevidence-based clinical protocols.

The application of a broad range of ICT asit applies to managing disease and wellnessis termed “telehealth.” It is broader than theconcept of “telemedicine,” which is typical-ly defined as a system of healthcare deliv-ery in which physicians examine patientsthrough the use of telecommunicationstechnologies – that is, remote diagnosis.Telehealth incorporates a wider range ofhealth-related activities including patientand provider education, point-of-care diag-nostics, clinical decision support services,

and most importantly, provides tools forself-management of disease and wellness.

The work of our research group in the tele-health area dates back some 15 years. Webegan by designing appropriate technolo-gies for use in primary health care. Thereare many examples of ICT applications inchronic disease management. However,many are ill-conceived in that they are driv-en by the underlying technology and notby a clinical problem that needs to be ad-dressed. Specifically, in 2001, we began totrial home telecare technology for the man-agement of chronic disease. At that time,much rhetoric existed about the perceivedpatient benefits and potential cost savingsof the “tele” word when applied to health-care. How important is the clinical need interms of improving health care and reduc-ing current costs? Does the proposed tech-nology impact significantly on the clinicalproblem? Is there adequate input from all

To Telehealth and Beyond

By Nigel H. Lovell &Stephen J. Redmond

By offering manyadvantages to

patients and care-givers alike, tele-

health is becomingincreasingly popular

and also morestreamlined as relat-ed technologies arefurther developed.

FEATURES

Figure 1: A patient uses TeleMedCare’s telehealth system to record a single lead electro-cardiogram.

25


FEATURES

stakeholders including patient groups andend-user representatives? Surprisingly, inmany forums the questions that were be-ing asked then are still being asked today.

Over the last eight years the telehealth tech-nologies developed at UNSW have beencommercialized in Australia by a start-upcompany (TeleMedCare Pty. Ltd.,http://www.telemedcare.com.au) and ex-tensive product and clinical trials have beenundertaken both in Australia and the U.K.

While it was, and still is, an evolving process,appropriate home telehealth technologieswere engineered into health care solutionsthat were then integrated with existinghealth service delivery models. These sys-tems were researched, constructed and tri-alled. A range of health management solu-tions are now being sold and deployedthroughout Australasia and the U.K. to hos-pitals, local health authorities, residentialaged care facilities, community care cen-

ters, medical insurers, health and lifestylecenters and individuals.

In more recent times, the telehealth spacehas attracted interest from bigger multi-national companies. Examples include theViterion product from Bayer-Panasonic,HomMed from Honeywell, TeleStationfrom Philips and the PHS600 from Intel-GE. In general, all the units are designedto record clinical indicators of a patient’shealth status including weight measure-ment, single lead electrocardiogram, bloodpressure, spirometry, body temperatureand oxygen saturation (pulse oximetry).Some systems provide feedback to pa-tients, including medication reminders andmeasurement scheduling, as well as videoconferencing.

Just as the clinical interventions when man-aging chronic and complex disease requirea holistic approach, so too does the hometelehealth approach. There exists no singlesilver bullet for design of an effective tele-health system. The chronic disease condi-tions by their nature are complex and mul-ti-factorial – and so too are therequirements for a telehealth managementsystem. The critical issue in deploying a us-able system is to firstly have a deep under-standing of the healthcare sector and touse this understanding to appropriatelyhide the layers of complexity from the end-users. A patient interacts with the systemby way of scheduled measurements andmedications reminders. By default, a clini-cian views management reports from onlyhis or her patients with adverse or deteri-orating clinical measurement trends.

From a systems viewpoint, to make suchcomplex tasks appear simple and be timeand cost effective requires a convergence

of many factors – in-tegration of innova-tive, low-cost sensorsto perform clinicalmea su remen t s ,scheduling for med-ications and meas-urements, a longitu-dinal history of pastmeasurements andappropriate tools in-

cluding targeted patient education to facil-itate patient self-management, remotelymaintainable client-side software, and webservices for case management by healthcare workers and administrators.

Research and trials in Australia and the U.K.have clearly demonstrated that the TeleMed-Care system is a viable and important wayof providing monitoring and follow-up careto patients suffering the burden of chron-ic disease. Studies have shown that nearly90% of the care a person needs to managea chronic disease must come directly fromthe patient. Self-management interventions,such as self-monitoring, patient educationand feedback, and decision making lead notonly to improvements in health outcomes,but also to increased patient satisfaction

and reductions in hospital bed days and car-er visits. By way of example, the Veteran’sHealth Administration (VHA) in the U.S. ranan extended trial of rudimentary telehealthequipment from 2003-2007. In a studygroup of over 17,000 patients, the introduc-tion of home telehealth demonstrated a25% reduction in numbers of bed days ofcare, 19% reduction in numbers of hospi-tal admissions, and mean satisfaction scorerating of 86% after enrollment into the pro-gram. This was also associated with consid-erable projected cost savings.

Another essential, on-going task is the de-velopment of a decision support frameworkto enhance the healthcare giver’s review ofthe remotely acquired monitoring data andto support the clinical decision-making ex-perience. The amount of clinical informa-tion that can be generated from a telehealthmonitoring system is substantial. Analysisof these data and correlation with clinicalhistory by the decision support system willbe used to highlight important sections ofpatient results, provide summary analysesand recommendations, and will assist in theefficient review and risk stratification of mul-tiple patient results. The healthcare giver willautomatically be alerted if any of the mon-itored data indicates deterioration in thehealth status of a patient. Furthermore, out-puts from the decision support system canbe used to influence changes in work flow.

The path to creating a comprehensive andholistic home telehealth system is hugelyintegrative and complex. It is only now af-ter a decade of intense development andtrialling that we are beginning, in a con-trolled and automated way, to effectivelyand efficiently close the clinical care man-agement loop. Such modifications to theclinical care workflow will flag the way forthe next generation of home telehealth.

[ ]Nigel H. Lovell , Ph.D.Stephen J. Redmond, Ph.D.University of New South WalesAustralia

[email protected]

“Telehealth incorporates a wider range ofhealth-related activities including patient andprovider education, point-of-care diagnostics,clinical decision support services, and mostimportantly, provides tools for self-manage-ment of disease and wellness.”

26

PRODUCT

IVT Mobile Health

Management and

Rescue System

HealthPal

INTERSTRESS– Inter-

reality in the Man-

agement and Treat-

ment of Stress-Related

Disorders

VeriChip RFID Tag

E-Textile Pants

SensorART

REACTION

LifeVest – Wearable

Defibrillator

MONARCA – MONitor-

ing, treAtment and

pRediCtion of bipolAr

disorder episodes

DESCRIPTION OF PRODUCT

S120 mobile phone, wireless blood pres-

sure meter, a wireless ECG monitor, a wire-

less pulse oximeter, a wireless glucose

meter and a wireless PSTN access point

cuff that straps around the upper arm that

corresponds to a cell-phone-sized trans-

mitter

monitors patients’ health, emotions, be-

havior, and activities while immersed in

a shared 3-D virtual world; can be used

in health care centers and at home, also

utilizes mobile phone and PDA technol-

ogy to provide support

an 11 mm long RFID tag that is inserted

just below the flesh of a person’s upper

arm

pants lined with e-TAGS (small circuit

boards that contain microcontrollers, sen-

sors, and communication devices), gyro-

scopes and accelerometers at the ankles,

knees and hips

remote controlled Sensorized Artificial

heart designed for treating patients with

heart failure

wireless wearable non-invasive and

minimally invasive sensors monitor

physiological vitals of patients with di-

abetes and transmits data to healthcare

professionals

an electrode belt worn around a pa-

tient’s chest and includes a small mon-

itor weighing about 2 lb. that hangs from

a shoulder strap

includes sensor-enabled mobile phone,

a wrist-worn activity monitor, a sock with

GSR and pulse sensors, an EEG system,

and a home gateway

MANUFACTURER

IVT Corporation

MedApps, Inc.

an EU-funded

project

Applied Digital

Solutions

Virginia Tech

an EU-funded

project

an EU-funded

project

Zoll

an EU-funded

project

FUNCTION

user can measure related criteria, upload to

personal E-Health record on a remote serv-

er where data is saved and analyzed in real

time, rescue center provides 24-hour service

sends blood pressure wirelessly to online

database, where if abnormalities occur, a

doctor will be alerted and call the patient

ICT strategy for the assessment and treatment

of psychological stress by regulating patients’

emotional coping skills and physiological re-

sponses to virtual worlds, through the use

of biosensors and behavioral analysis that

can be applied to the real world

contains a personalized 16-digit number, that

once scanned will provide immediate iden-

tification and medical records

designed mainly for the elderly, it monitors

motion and activity; it is able to detect the

motion of falling, which then results in a sig-

nal for help through a wireless transmitter

provides constant monitoring that will help

doctors to better treat heart failure in pa-

tients, and aid in the recovery process

through close analysis of heart patterns

regulates insulin dosages, gives personalized

feedback to patients and healthcare

providers, and ensures emergency and cri-

sis support to enhance therapy management

and self-monitoring capabilities

electrode belt senses abnormal heart rhythms

that cause wearer to become unconscious

and delivers electric shock, restoring normal

heartbeat and consciousness

utilizes GPS tracking, physical motion infor-

mation, recognizes eating habits, etc.; in-

formation is updated onto a profile that aids

diagnosis and treatment

Product Comparison Chart:Personalized Health Systems

PRODUCT COMPARISON

RESEARCHER:

Christina Valenti, Editorial DepartmentC&R Magazine

www.vrphobia.eu, [email protected]


FEATURES

For the past number of years diabetes mel-litus has gained importance globally as amajor public heath concern. The chronichigh glucose levels in blood can be a fur-ther risk for other serious micro-vascularcomplications, such as stroke, atheroscle-rosis, and coronary artery diseases. The dataprovided by the International Diabetes Fed-eration shows that, for the year 2010, morethan 6% of the world population sufferedfrom diabetes mellitus.

Self-monitoring of blood glucose is wide-ly used for controlling glucose levels. Thisis usually performed by a "finger prick" testusing a portable meter. However, this sens-ing method is invasive; it requires directcontact between the sensor and the blood.More importantly, it can provide only a sin-gle temporal value – it cannot follow therapid fluctuations of blood glucose levelsduring diabetes medication. Hence, a non-invasive continuous glucose sensingmethod would be strongly preferred forthe next generation of human health mon-itoring.

Non-invasive detection is usually achievedby placing the sensing element on the skin,and sensing tissue glucose without pierc-

ing the skin, using techniques such as ab-sorption spectrometry and polarimetry.But these methods require both the sen-sor and various auxiliary components forpractical operation, which make them lessportable. An alternative way of non-inva-sive sensing can be achieved by takingmeasurements from body fluids, such asurine, saliva, sweat or tear fluid. Besidesthe drawback of the variable water con-tent, or dilution effect, urine cannot be ac-cessed in a continuous basis, and placingsensors in the mouth is uncomfortable.Compared with the difficulty encounteredin sweat harvest, tear fluid is directly ac-cessible on the eye and can provide aunique interface between the sensor andthe body. As reported in prior clinical stud-ies, there is a correlation between the tearglucose and the blood glucose, for bothnondiabetic and diabetic groups.

Our group aims to build a contact lenscomplete with sensors and radio to sam-ple the tear fluid, perform an analysis, andwirelessly transmit the results. The con-tact lens allows for monitoring humanhealth non-invasively and continuouslythrough the tear fluid. This contact lenscan be built on a polymer platform, com-

plete with a biosensor module, communi-cation circuit, antenna and embedded in-terconnects, leaving the central area clearfor the visual path (Fig. 1). Sensor place-ment in tear fluid permits the use of con-tinuous sensing mode, which would pro-vide a more complete understanding ofthe human health status. The contact lensmay have the potential benefit of elimi-nating the finger prick test and increasecompliance with glucose monitoringamong diabetic patients.

Challenges for glucose sensor design in-clude the need for enhanced sensitivityand interference rejection, especially forglucose measurement in the tear fluid, be-cause the glucose levels in tears are muchlower (0.1~0.6 mM) compared with bloodconcentration (4~6 mM), and there are var-ious interfering molecules, such as ascor-bic acid, lactate, and urea present on thesurface of the eye. Also, different proteinscould influence the sensor output. As a re-sult, detection requirements for a tear glu-cose sensor are more stringent than thosefor a blood glucose sensor. In our project,we chose an electrochemical sensingmethod to analyze the tear fluid due to itsreal-time, fast, and easy operation. We de-

30

Contact Lens with IntegratedSensors for the Next Generationof Human Health MonitoringWith 6% of the world population suffering from diabetes in 2010, the far-reach-ing impact of the disease cannot be ignored. Monitoring blood glucose remainsan important step in treatment, although the finger-prick method deters manypatients from consistently tracking data. Here, the authors discuss cutting-edgetechnology implementing contact lenses to continuously monitor glucose levelsand wirelessly record data.

By Huanfen Yao, Ilkka Lähdesmäki & Babak A. Parviz


veloped a dual microscale sensor designfor interference compensation (Fig. 3),where the primary sensor responds to glu-cose while both the primary and the con-trol sensor respond equally to the inter-ferences. Different response behavior onthe primary and the control sensor is dueto different surface treatment. When a dif-ference signal is calculated, the interfer-ence response is removed while the glu-

cose response is preserved. We have fab-ricated such a dual sensor on a PET (poly-ethylene terephthalate) substrate anddemonstrated that it can be successfullyused for sensing low concentrations of glu-cose in the presence of interfering chem-ical ascorbic acid (Fig. 2).

Another challenge for developing the ac-tive contact lens is the construction of the

wireless power transmission and readoutcircuitry parts to support the sensor. Fig-ure 3 shows the wireless sensing systemsetup which we developed for test andcharacterization. For measurement, weused a horn antenna to broadcast radiowaves towards a custom-designed radiochip designed at the University of Wash-ington. A loop antenna, which can be fab-ricated on the contact lens, is used to col-lect the radio frequency wave power andsupply it to the circuitry. The same loopantenna can also transmit data, in form ofa shift in peak frequency. The current sig-nal from the sensor is converted to a shiftin the frequency spectrum through thereadout circuit. Thus, glucose concentra-tion data can be transferred from the sen-sor to an external storage unit as frequen-cy spectra wirelessly.

At this stage, we have managed to fabri-cate the circuitry part in a small chip of0.5 mm2, which provides a potential toconstruct the glucose sensor and support-ing circuit on a single contact lens in thefuture. We have also obtained linear meas-urement results for glucose up to 2 mM,by reading the frequency shift using thewireless sensing method. Combining thedual sensor and the communication cir-cuitry part, we hope to build a wirelessnon-invasive continuous glucose sensorin the future.

Our active contact lens is still under de-velopment and far from complete. Futureimprovements will include more biocom-patible encapsulation, building low noiseinterfaces, and complete component in-tegration. We believe that an integratedcontact lens could be the next generationsystem to monitor several physiologicaland metabolic indicators for humanhealth, in a wireless, non-invasive and con-tinuous way.

31

Figure 1 (top): A conceptual active contact lens; Figure 2 (middle): Typical meas-ured amperometric response of the dual sensor for glucose (G) and ascorbic acid (A);Figure 3 (bottom): Schematic of our test set-up for the wireless sensing and imageof the dual glucose sensor.

FEATURES

Huanfen Yao, MScIlkka Lähdesmäki, Ph.D.Babak A. Parviz, Ph.D.University of WashingtonU.S.A.

[email protected][ ]


Recent research results show thatmental activity, as well as social inter-action, is a key prerequisite for allevi-ating dementia. SOCIABLE is highlymotivated by the fact that a combina-tion of physical and mental activity,along with social engagement and abrain-healthy diet, is more effectivethan any of these factors alone. Hence,the SOCIABLE project will pilot a rad-ically new ICT-based approach for in-tegrated support of mental activity, aswell as boosting of social interactionfor individuals that have been diag-nosed with mild dementia.

Methodology of the SOCIABLE Project

This new approach will build uponthree tested technological pillars, whichhave proven been proven to be of ther-apeutic value, namely: (a) Novel per-ceptive mixed reality interfaces basedon multi-touch surfaces, (b) A modu-lar platform for cognitive traininggames development, which allows theflexible creation and customization of

cognitive training games and (c) “Pro-filing” and social “matching” capabili-ties boosting social networking and in-teraction between elderly individuals.

SOCIABLE will combine the ever-im-portant factors of human care and sup-port with innovative ICT-enabled serv-ices (notably, services available oversurface computing infrastructures) andindependent living technologies.Specifically, SOCIABLE will integratehuman support and care services of-fered by care centers, health profes-sionals and specialized medical ex-perts, with state -of-the-art ICTinfrastructure and independent livingtechnologies enabling elderly users to:

• Access a motivating recreational on-line (and offline) environment basedon mixed reality interface technologiesand play-related-therapeutic tools with

an aim to prevent and alleviate the evo-lution of dementia through pleasantcognitive training-gaming activities forelderly people. This environment willinclude interaction ranging from indi-vidualized cognitive training, team/group play, to a network of social acti-vation activities involving multiple eld-erly users that reside in geographicallydiverse locations.

• Provide an automated tool for man-aging elderly patients’ related data and

32

THE SOCIABLE Project:Motivating platform for elderlynetworking, mental reinforce-ment and social interaction

By Mariano Alcañiz & Irene Zaragozá

“SOCIABLE will integrate human support and care servicesoffered by care centers, health professionals and specializedmedical experts, with state-of-the-art ICT infrastructure andindependent living technologies [to help enable] elderly users ...”

FEATURES

“Overall, SOCIABLE will integrate, deploy and operate an inno-vative ICT-enabled online service for assessing and accordinglyreinforcing the mental state of the elderly through pleasantgaming activities for cognitive training, while at the same timeboosting their social networking and activating their day-to-dayinterpersonal interactions.”


collecting measurements that supportthe assessment of cognitive status (im-provement or deterioration) of peoplewith mild dementia by experts. This in-

volves the provision of informationabout the elderly person’s mood, cog-nitive/functional/affective status andmental performance, as well as context-related information. Such informationwill be collected, maintained and pre-sented in a systematic way to supporthealth professionals and medical ex-

perts in care centers in interpreting thecognitive, functional and affective stateof elderly individuals with mild demen-tia and help in defining appropriate

training programsand other thera-peutic measures.

• Activate and/orincrease the qual-ity and quantityof elderly peo-ple’s social inter-

actions with other members of the age-ing society, as well as with relatives andfamily. This will be achieved by com-bining human knowledge residing withcaretakers about elderly patients’ pro-files and preferences with an innova-tive ICT-based social “matching” serv-ice offered through the SOCIABLE

platform that will instigate social inter-actions between elderly individualsand/or inter-generational interactionsto the benefit of all elderly parties.

• Participate in community building ac-tivities that are instigated by and buildon the results of the “matching” serv-ice. The SOCIABLE platform will sup-port elderly-specific networking, social-ization and community-buildingactivities that will enable building andpopulating groups of elderly individu-als that share similar problems and/orcan benefit from mutual social inter-action.

SOCIABLE will be piloted with the par-ticipation of a minimum of 350 seniorcitizens in seven different pilot sites(TRONDHEIM Kommune, Hygeia, Mor-gagni Pierantoni Hospital, Municipali-ty of Forlì, Social Policy Centre of theMunicipality of Kifissia, Santa LuciaFoundation and PREVI S.L) from fourEuropean countries (Greece, Italy, Nor-way, and Spain).

Conclusion

Overall, SOCIABLE will integrate, de-ploy and operate an innovative ICT-en-abled online service for assessing andaccordingly reinforcing the mentalstate of the elderly through pleasantgaming activities for cognitive train-ing, while at the same time boostingtheir social networking and activatingtheir day-to-day interpersonal interac-tions. SOCIABLE is envisaged as a serv-ice with a high potential for societalimpact that could add significant val-ue to current services offered for careservices providers.

33

FEATURES

[ ]Mariano Alcañiz, Ph.D.Irene Zaragozá , Ph.D.Universidad Politécnica de ValenciaSpain

[email protected]

Figure 1: Screens illustrating some aspects of the SOCIABLE application.

“SOCIABLE will be piloted with the participationof a minimum of 350 senior citizens in sevendifferent pilot sites from four European coun-tries (Greece, Italy, Norway, and Spain).”


Traumatic brain injury (TBI) occurs whena sudden trauma causes damage to thebrain. Every year, over 1,600,000 patientssustain a traumatic brain injury in theEU, and 70,000 of these die, with a fur-ther 100,000 being left handicapped.Significantly, 75% of the victims are chil-dren and young adults, and TBI is theleading cause of disability in people un-der 40 years of age. TBI results in morelost working years than cancers, strokeand HIV/AIDS together. On a globalscale, the number of life years lost dueto TBI is four times that of diabetes-re-lated loss. Recent statistics show a steepincrease in the incidence of TBIs, withan increase of 21% over the last fiveyears – threefold greater than the rateof increase in population. Despite this,TBI has been seriously underrepresent-ed in medical R&D efforts compared tomany other, less significant health prob-lems.

Due to a vast degree of variation in theinjuries of individual patients, the meth-ods currently in use in the treatment ofbrain injury patients lack strong scientif-ic evidence. The EU-funded project TBI-care provides an objective and evidence-

based solution for management of TBIby improving diagnostics and treatmentdecisions for an individual patient bymatching a patient’s individual data withthe injury’s characteristics. In this way itallows each brain injury patient to receiveindividual treatment that is optimizedfor his or her needs.

The project develops a tool that willmake the day-to-day clinical work of doc-

tors easier and also revolutionize thetreatment of TBI. This software tool willenable doctors to match the patient-re-lated variables with the injury-relatedvariables through the combined use ofvarious databases. Using extensive data-base and system simulation, the soft-ware will then form a detailed analysisof the nature of the patient’s brain in-jury, its optimal treatment and predict-ed outcome. A scenario illustrating the

34

Developing Personalized Solutionsfor the Treatment of TraumaticBrain Injury:

The TBIcare Project

By Mark van Gils & Olli Tenovuo

“Providing an objective and evidence-based solution for themanagement of traumatic brain injury, by improving diagnos-tics and treatment decisions for an individual patient.”

FEATURES

TBIcare scenario: Harry has been in a serious car accident. When enter-ing the University Hospital, he is conscious but somnolent, confused andsuffers from severe headache. Other bodily injuries include a pelvic frac-ture with moderate intra-abdominal bleeding, as well as external woundsand crushes. All clinical parameters are checked carefully, includingdetailed assessment of vital and neurological functions. A laboratoryscreen is carried out, including available measures of brain injury bio-markers and general physiologic state. A head and body CT-scan is takenafter stabilizing the vital functions. Brain CT reveals diffuse axonal injuryand fronto-temporal contusions.

The main question is: should the pelvic fracture be stabilized operativelydue to bleeding or is external stabilization sufficient – which solutionforms a smaller risk for the injured brain? All clinical, imaging, and labo-ratory values have automatically been transferred into the TBIcare soft-ware which calculates the expected risks for the available treatment alter-natives in regard to TBI outcome, thus helping the treating clinician tomake the best choice. Corresponding treatment decisions will be madeseveral times during the acute in-hospital care period, each time with thehelp of TBIcare which has collected the relevant variables during the stay,thus guiding the care to produce an optimal outcome.


TBIcare concept is given in the box text.

The project has two scientific objectives;development of1) a methodology for finding efficientcombinations of multi-modal biomark-ers in statistical models to objectivelydiagnose and assess an individual TBIpatient, and 2) a simulation model based for objec-tively predicting outcome of the plannedtreatment of an individual TBI patient.

The first objective is addressed by usingan approach in which a high number ofvital signs or biomarkers, relevant toTBIs, are explored from sets of hetero-geneous data. These include, for exam-ple, structural and functional changesvisible in imaging data (computerizedtomography, CT; magnetic resonance im-aging, MRI; positron emission imaging,PET), changes in electrophysiology (elec-troencephalography, EEG); changes inbedside multimodality monitoring pa-rameters including systemic cardiac andrespiratory physiology, intracranial pres-sure (ICP), and brain chemistry (moni-tored by oxygen sensors and microdial-ysis); and changes in metabolomicsvisible in the blood. We define sets ofbiomarkers from several thousand braininjury cases retrospectively, and fromseveral hundred TBI cases and healthycontrols prospectively. The goal is tobuild statistical models allowing stan-dardized and objective interpretation ofdata from a single patient. The diagnos-tic rules are derived by comparing thepatient data to the most similar casesin a database using statistical inference.

Work towards reaching the second ob-jective uses these statistical models asa basis for the construction of a simula-tion model. Due to the unique respons-es to treatments, the simulation modelmust be individualized. The model ispersonalized for each patient separate-ly using data only from similar cases.Various approaches can be used for thesimulations, such as concepts from sys-tem dynamics or Bayesian networks. Inthe TBIcare concept individual physio-logical measures and various treatments

form the building blocks of the systemdynamics model which is used to pre-dict the outcome.

The simulation model provides impor-tant information both for scientists andclinical practitioners. It helps a scientistto better understand a human as a sys-tem – a viewpoint central to the Virtu-al Physiological Human. A clinician isable to test the influence of varioustreatments by first simulating them. Asthe variability of the individuals andtraumas is huge, we do not expect thata simulation model built from hundredsof cases is enough for reliable predictionof the outcome. However, our aim is todevelop a strictly evidence-based simu-lation model for objectively predictingthe outcome of treatment and rehabil-itation of an individual TBI patient. Themodel provides objective evidence-based information about the most prob-able outcome and will be a step towardsa scientifically valid approach for treat-ment planning. This model will be a ba-sis for future development, where an in-creasing amount of validated clinicaldata will continuously improve the reli-ability and usability of the model. In ad-dition, this kind of model may be usedto optimize the diagnostic procedure inTBIs, e.g. it may advise the clinician totake some further tests in order to im-prove the reliability of the model for acertain individual.

These scientific objectives are supple-mented by realization of technical ob-jectives: a software solution to be usedin daily practice to diagnose and plantreatments; new approaches for extract-ing information from multi-source andmulti-scale physiological databases formanagement of an extremely heteroge-

neous disease; and innovative data quan-tification methods for the clinical TBIenvironment. Thus, TBIcare transfers the

scientific Virtual Physiological Human(VPH) concepts to clinical practice.

TBIcare has impacts for healthcare pro-fessionals by improving the healthcareprocess and increasing medical knowl-edge; for the patients and their near-est by increased quality adjusted lifeyears; for society it brings reduction inhealthcare costs and losses due toworking disability, and for the Europeanindustry it brings an impetus to in-creased global competitiveness by pro-viding immediately exploitable inno-vative methods.

This work is supported by the EuropeanCommission under the 7th FrameworkProgramme (FP7-270259-TBIcare). ThisEU co-funded project has started on 1February 2011. It is co-ordinated by VTTTechnical Research Centre of Finlandand the consortium includes GE Health-care Ltd. (UK), Turku University CentralHospital (Finland), University of Cam-bridge (UK), Imperial College London(UK), Complexio S.a.r.L. (France), KaunasUniversity of Technology (Lithuania), andGE Healthcare Finland Oy.

35

FEATURES

[ ]Mark van Gils , Ph.D.VTT Technical Research Centreof FinlandOlli Tenovuo , Ph.D.Turku University Central HospitalFinland

[email protected]@tyks.fi

“The EU-funded project TBIcare provides an objective and evi-dence-based solution for management of TBI by improvingdiagnostics and treatment decisions for an individual patientby matching a patient’s individual data with the injury’s char-acteristics ... it allows each brain injury patient to receive indi-vidual treatment that is optimized for his or her needs.”

The way that healthcare systems operateis going to change forever. In most cas-es, primary care is currently delivered bygeneral practitioners (primary care physi-cians) or community care nurses. In somecases, certain individuals will even attendthe emergency department in tertiaryhospitals to obtain primary care, withoutreferral. This model of care is inherentlyreactive in nature and therefore subop-timal in its utilization of valuable health-care resources; the individual interpretstheir symptoms and then seeks primarycare when they deem appropriate. Evenif visits to tertiary care centers are by re-ferral from primary care physicians, of-ten hospital admission may be unavoid-able as the patient may not recognize theseverity of their condition at an earlyenough stage to avoid hospitalization.

One acute example of this scenario re-lates to falls among elderly individuals.Falls and fall-induced injuries amongthe elderly population are a major causeof morbidity, disability and increasedhealth care utilization. It is estimatedthat approximately one in three personsover the age of 65 years old fall one ormore times each year; this ratio rises toabout 50% for persons over the age of80 years old. In Australia alone, in 2003-2004, the cost of fall-related hospitaliza-tion is estimated to have exceeded U.S.$500 million. Through early interven-tion using physical rehabilitation strate-gies which are tailored to address the

functional deficits of the individual, fu-ture falls may be prevented; however,those individuals at risk of falling mustfirst be identified.

Falls-risk assessment is currently a veryactive research area spurred on by ouraging populations in developed nations.Many clinical falls-risk indices have been

36

Healthcare in FreeFall


“... the Internet will continue to permeate into our everyday lives, and it is only a matter of time

before healthcare systems change the way they do business andbegin to make full use of this incredible communication resourceat their disposal.”

Figure 1: Subject wearing a wireless ambulatory monitor attached to a belt placedaround the waist. The triaxial accelerometer in this device is used characterize thesubject’s performance of a number of physical assessments and hence determinetheir risk of falling in the near future.

By Stephen J. Redmond & Nigel H. Lovell

FEATURES

developed based on questionnaires regard-ing previous falls, observations of gait, andbalance and postural change maneuvers.Often, these methods require specializedequipment and the presence of a trainedassessor which limits their capacity to mon-itor and screen the general population.

In recent years, through the miniaturiza-tion of sensor technologies and the matu-ration of wireless communi-cation protocols, it hasbecome feasible to addressthe shortcomings in tradition-al clinical falls-risk assess-ments, and bring reliable con-tinuous assessment offalls-risk to the home. Specif-ically, microelectromechani-cal sensors (MEMS), whichcan measure acceleration,rate of rotation and baromet-ric air pressure, are used. Allsensors and a wireless transceiver arehoused in a single device and worn on thehip, which enables the reliable characteri-zation of human movement.

Our group at the University of New SouthWales has developed a directed routinewhich includes a short battery of com-monly used physical assessment tasks.These tasks are performed unsupervisedin the home and can be characterized us-ing a single triaxial accelerometer device(designed at our laboratories), clippedonto a belt around the subject’s waist (seeFig. 1). Explicitly, the direct routine con-sists of three physical assessments – risefrom a chair, walk three meters and re-turn to the chair; place the left foot on asmall step, then back to the floor, thenthe same with the right foot, and repeatfour times; and stand up and sit downfive times. The resulting accelerometrysignals are analyzed to extract informa-tion relating to speed, strength and bal-ance, and are employed in a model whichestimates the subject’s risk of falling. Re-sults from testing on 68 elderly subjectsshow that the falls-risk estimates gener-ated by the model correlate extremelywell (99%) with a commonly used clini-cal falls-risk assessment test – the Phys-iological Profile Assessment.

To provide some background in regards tohow such monitoring technologies mightfind their way into the home environ-ment, we need to examine the currentstate of fall detection devices. Fall detec-tion technologies, which are different inthat they identify the occurrence of a fallafter the event, are beginning to mature,although high false positive alarm ratesstill pose a challenge which needs to be

overcome. The marketplace for such tech-nologies is competitive and already crowd-ed, with monitoring devices availablefrom: Tunstall (Tunstall Group, UK); iFall(Android mobile phone ‘App’); VerhaertZenio (Verhaert¸ Kruibeke, Belgium); Well-core Personal Emergency Response Sys-tem (Wellcore, San Jose, CA, USA); myHa-lo Fall Detection Device (myHalo, Novi,MI, USA); and, Philips Lifeline with Au-toAlert (Philips, Amsterdam, the Nether-lands). It is becoming apparent that falldetection devices, in whatever final formthey assume, will become an establishedtechnology for monitoring the elderly athome. Therefore, it can be envisaged thatfuture fall detection technologies in thehome will eventually include some typeof falls prevention strategy, similar to themethod described earlier.

The key factor in the success of all of thesetechnologies is the Internet. The ability tounobtrusively retrieve patient health infor-mation from their home, act on this infor-mation, and issue health management rec-ommendations from a distance will openup a world of possibilities for healthcare.While the transition will be painful, changeis coming. As the Australian governmentcurrently ponders the pros and cons ofspending up to U.S. $43 billion on a pro-

posed initiative to install fiber optic cable,carrying broadband speeds of approximate-ly 100 Mbits/s, to every home in the coun-try, the migration of primary healthcare tothe home is proving to be one of the crit-ical issues driving the debate. Irrespectiveof the successes of Australia’s NationalBroadband Network, the Internet will con-tinue to permeate into our everyday lives,and it is only a matter of time before

healthcare systems change the way theydo business and begin to make full use ofthis incredible communication resource attheir disposal.

We plan to trial our falls-risk assessmenttechnology on a larger scale, and in a com-pletely unsupervised setting, over the nextyear. We are currently redesigning the unitso it will not only record acceleration, butwill contain gyroscopes (to measure angu-lar velocity) and a barometric air pressuresensor (to detect changes in the device al-titude), improving how well human move-ment may be characterized. A speaker willalso be added so that a voice recording mayguide the user through the directed rou-tine assessment, since they will be other-wise unsupervised. It is our hope that inthe coming years, this form of monitoringtechnology will significantly improve thequality of life of an aging population by re-ducing their incidence of falls.

37

FEATURES


“It is becoming apparent that fall detection devices, in what-ever final form they assume, will become an established

technology for monitoring the elderly at home. Therefore, itcan be envisaged that future fall detection technologies inthe home will eventually include some type of falls preven-

tion strategy, similar to the method described earlier.”

[ ]Stephen J. Redmond, Ph.D.Nigel H. Lovell, Ph.D.University of New South WalesAustralia

[email protected]

Brain Machine Interfaces (BMIs), a tech-nology that is only about 10 years old,promises to revolutionize the way we di-agnose and treat a wide variety of neuro-logical diseases and disorders. Broadly de-fined, a BMI system provides a directcommunication pathway between thebrain and a man-made device. The lattercan be a an active circuit on a silicon chip,an artificial limb, or even a network ofcomputers. The overarching theme ofBMIs is the restoration/repair of damagedsensory, cognitive and motor functionssuch as hearing, sight, memory and move-ment via direct interactions between thenervous system and these artificial devices.It may even go beyond simple restorationto conceivably augment these functions,previously imagined only in the realm ofscience fiction.

Some striking advances in microfabrica-tion technology and systems engineering,coupled with substantial progress in inva-sive brain surgery, have fueled the briskevolution of BMIs. It is now feasible to im-plant arrays of microelectrodes in selectbrain areas for sufficiently long periods oftime to monitor signals from small pop-ulations of brain cells. These signals cannow be decoded and used to control ex-

ternal devices, such as robotic limbs, oreven be used to stimulate the subject’snatural arms. The interface technology,however, is not restricted to invasive tech-niques and now encompasses the use ofnoninvasive recordings (e.g. EEG), albeitat the expense of much lower temporaland spatial resolution, to monitor global

brain states during a variety of experimen-tal conditions.

Reliable and sustained brain recordings inpatients interacting naturally with theirsurroundings is key for clinically viableBMIs. This is in part because many com-plex brain mechanisms during the normal

Brain Machine Interfaces forPersonalized NeurologicalDiagnostics and Therapy

38


FEATURES

By Karim Oweiss

“The overarching theme of BMIs is the restoration/repair of damagedsensory, cognitive and motor functions such as hearing, sight, mem-ory and movement via direct interactions between the nervous sys-tem and these artificial devices. It may even go beyond simplerestoration to conceivably augment these functions, previously imag-ined only in the realm of science fiction.”

Figure 1: Brain Machine Interfaces may replace natural sensorimotor transformationin subjects with severe motor deficits. (M1 = Primary Motor Cortex, S1= Primary So-matosensory Cortex, V1 = Primary Visual Cortex).

and pathological states can only be mon-itored over prolonged periods of time,such as detecting epileptic seizure onset.Wireless BMIs constitute one major focusof the community to allow continuousmonitoring of brain states in patients athome by telemetering neural data con-tinuously to promptly alert the caregiver.The opportunity for immediate interven-tion also exists by stimulating or modu-

lating brain activity through BMIs to com-bat potential symptoms of abnormal brainactivity.

The pace of research in this area is rapidto the extent that new techniques contin-ue to swiftly emerge. The paradigm shiftbeing witnessed now in understandingbrain function as a result of advances inBMIs is already paving the way for the

technology to become a building block ina myriad of emerging clinical applications.


39

FEATURES

By Alessandro Tognetti et al.

Figure 1: Wearable bio-monitoring systems.

[ ]Karim Oweiss, Ph.D.Michigan State UniversityU.S.A.

[email protected]

Wearable Systems for Brain-body Reading and Mind Healing

People express their mental statesthrough gesture, posture, facial expres-sion, eye gaze, prosody and vocal tones.Hidden physiological parameters such asHeart Rate (HR), Heart Rate Variability(HRV), Respiration Rate (RR), and electro-dermal response (EDR) are somehow cor-related to emotions and thoughts. Ubiq-uitous monitoring of physiological andbehavioral correlates of complex mentalstates might prove instrumental in pro-viding insight in dealing with mental dis-orders.

Our group is involved in the develop-ment of fully wearable interfaces for un-obtrusive monitoring of physiologicalsigns, activity and movement, eye gazeand facial expression to explore their po-tentialities in the management of men-tal disorders.

“Ubiquitous monitoring of physiological and behavioral corre-lates of complex mental states might prove instrumental inproviding insight in dealing with mental disorders.”

Our bio-monitoring research is mainly fo-cused on evaluating human Psycho-Physio-logical State (PPS) by processing peripheraland central signals acquired by non-invasivemonitoring systems (Fig. 1). The aim is to iden-tify differences between healthy and patho-logical subjects as well as healthy (patholog-ical) subjects in different psycho-physiologicalstates. Several domains are covered rangingfrom biomedical signal processing, sensors,embedded electronics, advanced analysis andcomputational intelligence. Most of the phys-iological signals are acquired by means of tex-tile-based systems, Electrocardiogram (ECG)and breathing activity through sensing T-shirtsand EDR through sensing gloves. ConcerningCentral Nervous System (CNS), standard in-strumentation such as clinical and high res-olution Electroencephalogram (EEG) are usedas a gold standard for cognitive investigation.Moreover, a compact head mounted eye-gazetracker has been developed in order to inves-tigate the functional connectivity betweenpupil size variation or gaze-point set and PPS.

Wearable interfaces for full body monitoring(Fig. 2) have been developed through the tex-tile integration of elastic sensors based onconductive elastomer (CE) materials. CE ma-terials show piezo-resistive properties – a fab-ric deformation can be related to a sensorelectrical resistance variation. CE materialscan be integrated into elastic fabrics withoutchanging the substrate mechanical proper-ties, thus maintaining user comfort duringthe monitoring phase. These innovative sens-

ing garments allow the monitoring of bodyposture and gesture in rehabilitation and hu-man machine interaction for disabled peo-ple. Furthermore, these systems were success-fully employed in behavioral studies withfunctional MRI during specific motor tasks.The main advantages of the described tech-nologies are the overall system lightness, flex-ibility and unobtrusiveness, and the low costsof the textile process. Current research is ori-ented towards the combined use of inertialand textile sensors in a data fusion approachin order to address the limitations of the sys-tems that are currently available.

A new paradigm for the treatment of Autis-tic Spectrum Disorders (ASD) has been con-ceived and implemented in our lab by meansof the FACE android which is used as an in-teractive, physical display of emotional facialexpressions; a room in which the human-an-droid interaction takes place is equipped withmotorized cameras, directional microphones,smart wearable sensors for physiological sig-nals acquisition, and other acquisition anduser interaction systems as shown in Fig. 3.The physiological and gestural wearable in-terfaces are being used in several researchprojects focused on basic investigation, as-sessment, and treatment of psychological re-lated aspects.

In the EU-funded PSYCHE project, the de-scribed wearable bio-monitoring systems areused for the study and treatment of bipolarpatients.

Within the EU-funded INTERSTRESS proj-ect, whose aim is the physiological stresstreatment through virtual reality experiencesand continuous patient monitoring, a mo-bile personal bio-monitoring system is un-der development. This system will unobtru-sively perform a continuous tracking ofpatients’ physiological (HR,HRV, RR) and be-havioral status. Behavioral assessment is notintended for stress identification but for thedefinition of physiological measurementscontext.

Recent studies within the EU-funded CEEDSproject, are oriented towards the capture andclassification of explicit and implicit naviga-tion through mental states to investigate theprocess of discovering hidden data in hugemulti-dimensional datasets.

[ ]Alessandro Tognetti, Ph.D.Enzo Pasquale Scilingo, AssistantProfessor, Ph.D.Gaetano Anania, M.EngNicola Carbonaro, Ph.D.Antonio Lanatà, Ph.D.Federico Lorussi, Ph.D.Daniele Mazzei, Ph.D.Gaetano Valenza, M.EngDanilo De Rossi, Full ProfessorUniversity of PisaItaly

[email protected]

40

FEATURES Wearable Systems for Brain-body Reading and Mind Healing

Figure 2: Textile based motion sensing interfaces.

Figure 3 (right): Framework for the treatment of ASDdisorders through facial expression mimicking.

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Ask the Expert:

Brenda Wiederhold: Today I am in Brus-sels, interviewing Dr. Ilias Iakovidis fromthe European Commission. Dr. Iakovidis,I would like to start by asking what yourcurrent position is at the Commission?

Ilias Iakovidis: I am currently Acting Headof ICT for Inclusion. Until one month ago,I was Deputy Head of ICT for Health.

B.W.: Can you tell me what the significanceis of healthcare events that you help toorganize?

I.I.: We try to present past projects to politi-cians, industry members, users, stakehold-ers, and health care professionals in orderto involve them in the large-scale innova-tion and deployment process. In 2010 weheld a spring event targeting policy andpoliticians, and the fall event focusing onmarket forces.

B.W.: And how did you become interest-ed in technology and health care?

I.I.: I had an accidental interaction withcardiologists at my university when I was

a PhD student in the US, which ultimate-ly led to my thesis. After finishing my PhD,I was called by the Biomedical Engineer-ing Department in Canada to prove myPhD work. I applied my theory into prac-tice as a post-doc and later, as a researchassociate at the Montreal Heart Institute.I applied for a research officer position atthe European Commission while workingin Canada, and that came to fruition in1993. Now here I am – a "Eurocrat" man-aging R&D and policy in the domain ofhealth informatics, now known as eHealth.

B.W.: Can you tell me about the EuropeanCommission’s role in health care and tech-nology?

I.I.: The European Commission has hugeframework programs to facilitate researchand innovation, but it has a very weakmandate in healthcare, which is left to theMember States. Through the window ofa single market for eHealth systems andservices, the Commission has been oneof the first international funding organi-zations to focus on interdisciplinary proj-ects and research in eHealth since the end

of the ‘80s. We invested early, and gradu-ally increased. So from $10 million a yearat the end of the ‘80s, we are now at $100million a year. In the late ‘90s we startedworking with Member States, policy, in-dustry, users, stakeholders, and associa-tions. We then created European associ-ations of eHealth stakeholders likeEUROREC, EHTEL, and began policy workand deployment, based on solid researchground.

B.W.: It seems you have also been very in-volved in EU-US cooperation, is that cor-rect?

I.I.: Yes. We are involved in policy and re-search with the US, supporting global in-teroperability. Last December Vice-Presi-dent of the European Commission NeelieKroes and United States Secretary ofHealth and Human Services Kathleen Se-belius signed a Memorandum of Under-standing with the common aim to createnew markets and growth opportunitiesfor industry in the eHealth sector in boththe EU and the US.1 As well the ARGOSeHealth Pilot Project expands the impact

43

Ilias IakovidisActing Head of ICT for Inclusion,

European Commission

&

“In the near future, we could see peopleaccessing their records online, booking

appointments, requesting repeat prescriptionand volunteering for research trials. You givethe right tools to the patients and you get

them to have a ‘response-ability’ to cope withtheir condition.”

INTERVIEW

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of eHealth Week across the Atlantic: it de-velops and promotes common methodsfor responding to global eHealth challengesin the EU and the US.

B.W.: Are American universities involvedin the European research initiatives?

I.I.: Certainly. We had a special call invitingUS organizations to join our Virtual Physi-ological Human (VPH) initiative 2 projects.We are in close contact with several USfunding agencies working on VPH, mainlymulti-scale modeling and simulation.

B.W.: What would you consider the ICT forHealth’s main achievements for the pasttwo years?

I.I.: I think the biggest achievement wasgetting EU Member States to agree to forma high-level eHealth governance initiative.

B.W.: And what do you see some of themain initiatives being – moving for-ward for the remainder of 2011 and be-yond?

I.I.: We are working to break the legal bar-riers on patient identification and profes-sional authentication, to increase aware-ness of benefits by health professionals andpatients, and to get the health care profes-sionals and patients personally involvedwith eHealth.

B.W.: People talk a lot about how technol-ogy can improve healthcare, but what doyou think are some of the main impactsthat it will have on the individual’s health-care?

I.I.: We focused all of the ‘90s on connec-tivity - linking all the departments with-in a hospital, hospitals with GPs, pharma-cies, labs, payers and authorities. Now,we’re involving every person as a node ofthat network, receiving and sending vitalinformation. In the near future, we couldsee people accessing their records online,booking appointments, requesting repeatprescriptions and volunteering for re-search trials. You give the right tools tothe patients and you get them to have a“response-ability” to cope with their con-dition.

B.W.: In other words, empowering the pa-tients. Yes?

I.I.: Yes. We try to give the patient some kindof map or GPS to navigate through the roadof health, for their own sake.

B.W.: So do you see the individual EU citi-zen embracing the technology now, or doyou think most people are standing backwaiting?

I.I.: There are very big variations. That’s whyhealth care systems are so different. Theway a health care delivery system is organ-ized has to do with the relation between acitizen and the state. If they are very trust-ing of each other, it works marvelously. Youcan see Denmark as an example. We’re go-ing from a trust between people like meand the doctor, to trust between me and asystem. That’s huge – for some cultures,it’s an inconceivable jump.

B.W.: Several years ago, it seemed like therewas not as much in the mental health carearena with technology. But now it seemsthere is an emphasis on that. Are theremore things coming across with mentalhealth care?

I.I.: Yes. Until last year, we consciously keptaway from the human mental conditionbecause it was too complex for us to dealwith. So for the first time, we entered intothe game of mental disease and looking atthe bigger picture, but through quantita-tive measurements if possible.

B.W.: Can you tell me some of the biggestobstacles of incorporating technology intohealthcare as we go forward?

I.I.: Organization and skills are the prereq-uisite for getting benefits out of eHealth,and if you don’t have them, IT is just an-other expense. In addition, there are otherchallenges such as legal issues, incentives,trust among the stakeholders and finallytechnology. The technological componentsexist, but an integrated, user-friendly inter-face and a relevant kind of semantic inter-action is not yet there.

B.W.: What are you most proud of in allthese years at the Commission?

I.I.: I am very proud to have taken part indeveloping a vision of patient-centered care,as in 1994, and then seeing results materi-alize 10 years later. I also want to mentionthe renewing of the EU eHealth researchagenda twice: introducing personal healthsystems in 1998 – by forging stronger co-operation with biomedical engineers, andbiomedical informatics by forming strongsynergies with the system biology commu-nity in 2002 that lead to our VPH Initiativein 2005.

B.W.: And now, what are your recommen-dations to researchers seeking funding fromthe European Commission?

I.I.: A researcher should really understandwhat it is that can and has to be done; whatcan be funded at the European level, andwhat he can do nationally. Also, he shouldnot present a proposal that he is not fullydevoted to, because European money isvery competitive and very expensive mon-ey. It requires a really big effort and com-mitment.

B.W.: I think it is nice having different dis-ciplines from different organizations, anddifferent countries and cultures working to-gether to solve a problem. I think that isunique to Europe right now.

I.I.: Yes. Since we began funding projects in’89, we went through a phase of commu-nity building. We wanted people to createsomewhat of a single market of researchersin Europe. I think we are almost there. Nowwe need to focus on existing challengesthat need to be solved at the EU level.

B.W.: Any predictions on new trends thatyou see in this area?

I.I.: The one that we’re betting on is thestronger engagement of people. Some callit m-health or u-health. People will becomemore immersed in medical knowledge, sothey will be able to form an opinion andgive feedback. Another trend is personal-ized medicine. It’s not only about your treat-ment; it’s about your condition as a whole.This is a very difficult challenge to accom-plish.

B.W.: Thank you for your time.

1http://europa.eu/rapid/pressReleasesAction.do?reference=IP/10/1744&format=HTML&aged=0&language=EN&guiLanguage=en2en.wikipedia.org/wiki/VPH_NoE

44

ASK THE EXPERT Ilias Iakovidis


46

Within the health-care domain, the Eu-ropean Commissionfocus recently shift-ed from the tradi-tional hospital-cen-tered and reactivehealthcare deliverymodel toward a per-son-centered and

preventive one. The main outcome of this shiftis the “Personal Health Systems” (PHS) para-digm that aims at offering continuous, qualitycontrolled, and personalized health services toempowered individuals regardless of location.

PHS cover a wide range of systems includingwearable, implantableor portable systems, aswell as Point-of-Care (PoC) diagnostic devices.Typically, the functioning of PHS is related tothree main blocks as shown in Fig. 1.

1. Data Acquisition: Collection of data and in-formation related to the health status of a pa-tient or healthy individual, e.g., through theuse of sensors and monitoring devices.

2. Data Analysis: Processing, analysis and inter-pretation of the acquired data to identify whatinformation is clinically relevant and useful indiagnosis, management or treatment of a con-dition. This entails processing of data at bothends – locally at the site of acquisition (e.g., withon-body electronics) and remotely at medicalcenters. Data processing and interpretation takesinto account the established medical knowledgeand professional expertise where appropriate.

3. Patient/Therapist Communication: Commu-nication and feedback between various actors,in a loop – from patient/individual to med-ical center; from medical center that analyzesthe acquired data to doctor/hospital; and backto the patient/individual from either the wear-able/portable/implantable system itself or thedoctor or the medical center (e.g., in the form

of personalized feedback and guidance to thepatient, adjusted treatment via closed looptherapy, control of therapy devices).

The European Commission is supporting re-search in this area under the Seventh Frame-work Programme (FP7). FP7 funds are used tosupport research into monitoring systems forpatients with chronic diseases. In particular,such tools should provide improved quality oflife for chronically ill patients, enabling themto stay at home rather than have to be admit-ted to hospitals. With ICT systems able to mon-itor a range of parameters related to the pa-tient’s condition, medical professionals cantake timely decisions on the most effectivetreatment. Automatic alerts ensure doctorsare immediately made aware of changes inthe patient’s condition and can respond toprevent severe deteriorations.

This approach can also be used to improvemental health treatment. While most of us im-mediately think of either drugs or traditionaltalk therapy as the primary tools for mentalhealth problems, there is a long history of us-ing technologies for the diagnosis and treat-ment of psychological disorders. Specifically,PHS help us to connect on a level never seenin history, and for individuals less likely to seekprofessional help, they provide a confidential

self-paced avenue towards change.

For these reasons, the FP7 decided to supportICT-based research projects providing solu-tions for persons suffering from stress, depres-sion or bipolar disorders. These projects shouldaddress the parallel development of techno-logical solutions, as well as new managementor treatment models based on closed-loopapproaches. Emphasis will be on the use ofmulti-parametric monitoring systems, whichmonitor various metrics related to behaviorand to bodily and brain functions (e.g. activ-ity, sleep, physiological and biochemical pa-rameters).

Furthermore, the required systems should aimat (i) objective and quantitative assessment ofsymptoms, patient condition, effectiveness oftherapy and use of medication; (ii) decisionsupport for treatment planning; and (iii) pro-vision of warnings and motivating feedback.In the cases of depression and bipolar disor-ders, the systems should also aim at predic-tion of depressive or manic episodes. The so-lutions should combine wearable, portable orimplantable devices, with appropriate plat-forms and services. Finally, they should pro-mote the interaction between patients.

After a very demanding selection, the Com-

FROM WHERE WE SIT:What Can Personal Health Systems do for Mental Health?The European Answer

By Giuseppe Riva

Figure 1: The structure of a Personal Health System.

mission provided financial support to the fol-lowing six projects – Help4Mood, Ict4Depres-sion, Interstress, Monarca, Optimi and Psy-che – that aim at using PHS based on VirtualReality, biosensors and/or mobile technolo-gies to improve the treatment of bipolar dis-orders, depression and psychological stress.A short description of their contents is in theTable. The expected end outcomes of theseprojects are:

• Increased mental health practitioners pro-ductivity (i.e. reduced patient unit cost throughremote monitoring and self care).

• Reduced in-patient costs (i.e. due to delayof the time between when a disease becomescomplex and chronic and the end of life orto the elimination altogether of the develop-ment of pre-morbid conditions into a full-blown disease);

• Decreased diagnostic and treatment costssince a lower number of visits will be neededas a result of both preventive monitoring andchronic disease management.


47

FROM WHERE WE SIT

Giuseppe Riva, Ph.D.Istituto Auxlogico [email protected]

PHS for Mental Health: The European Projects

Project Goal

Help4Moodhttp://www.i2cat.net/en/pro-

jecte/help4mood-1

The project Help4Mood proposes to significantly advance the state-of-the-art in computerized support for people with MajorDepression by monitoring mood, thoughts, physical activity and voice characteristics, prompting adherence and promoting

behaviours in response to monitored inputs. These advances will be delivered through a Virtual Agent (VA) which can interactwith the patient through a combination of enriched prompts, dialogue, body movements and facial expressions. Monitoringwill combine existing (movement sensor, psychological ratings) and novel (voice analysis) technologies, as inputs to a pattern

recognition based decision support system for treatment management.

Ict4Depressionhttp://www.ict4depression.eu/

The overall aim of the project is to develop an intelligent (self-)support system for patients suffering from depression. Such asystem can only be effective if it will be accepted by the patient and perceived as useful. Hence, the system should be as

unobtrusive as possible and should provide sensible support. This leads to the two most important aims the project: develop-ing unnoticeable measurements of the behaviour of the patient and an intelligent analysis and communication of the

progress. For the monitoring of activities, behaviour and state of the patient, a combination of novel techniques that all arebeyond state of the art will be investigated.

Interstresshttp://www.inter

stress.eu/

The project aims to design, develop, and test an advanced ICT-based solution for the assessment and treatment of psycholog-ical stress based on “interreality”.The project’s creators define “interreality” as a hybrid, closed-loop, empowering experiencebridging both physical and virtual worlds into one seamless reality. In other words, behavior in the physical world will influ-ence the virtual world experience, and behavior in the virtual world will influence the real-world experience. Clinical use ofinterreality is based on a closed-loop concept that involves the use of technology for assessing, adjusting, and/or moderatingthe emotional regulation of the individual. This is achieved by increasing the individual’s coping skills and appraisal of theenvironment based upon a comparison of the individual’s behavioural and physiologic response with a training or perform-

ance criterion. The project will provide a proof of concept of the proposed system with clinical validation.

Monarcahttp://www.monarca-project.eu/

MONARCA will develop and validate solutions for multi-parametric, long term monitoring of behavioural and physiologicalinformation relevant to bipolar disorder. It will combine those solutions with an appropriate platform and a set of servicesinto an innovative system for management, treatment, and self-treatment of the disease. The MONARCA system will be

designed to comply with all relevant security, privacy and medical regulations, will pay close attention to interoperability withexisting medical information systems, will be integrated into relevant medical workflows, and will be evaluated in a statisti-

cally significant manner in clinical trials.

Optimihttp://www.optimiproject.eu/

Depression is often associated with poor coping behavior in the face of stress. Some individuals are extremely resilient butothers find it difficult to cope. Based on these premises, OPTIMI has set itself two goals: first, the development of new tools tomonitor coping behavior in individuals exposed to high levels of stress; second, the development of online interventions toimprove this behavior and reduce the incidence of depression. To achieve its first goal, OPTIMI will develop technology-basedtools to monitor the physiological state and the cognitive, motor and verbal behavior of high risk individuals over an extend-ed period of time and to detect changes associated with stress, poor coping and depression. To achieve its second goal, OPTI-

MI will adapt two existing systems, already used to provide online CBT treatment for mental disorders.

Psychehttp://www.psy-che-project.org

PSYCHE project will develop a personal, cost-effective, multi-parametric monitoring system based on textile platforms andportable sensing devices for the long term and short term acquisition of data from selected class of patients affected by mooddisorders. The project will develop novel portable devices for the monitoring of biochemical markers, voice analysis and abehavioral index correlated to patient state. Additionally, brain functional studies will be performed under specific experi-mental protocols in order to correlate central measures with the clinical assessment, and the parameters measured by Psycheplatform. The acquired data will be processed and analyzed in the established platform that takes into consideration the

Electronic Health Records (EHR) of the patient, a personalized data referee system, as well as medical analysis in order to veri-fy the diagnosis and help in prognosis of the disease.

[ ]


48

In China, the vastpersonal healthcareopportunities arecurrently being stim-ulated by an increas-ing demand from afast-aging popula-tion, rising income,and the tremendousgrowth of biomed-

ical products and services in the domestic bio-medical sector market. The growth of this ad-ditional demand for medical care and deviceshas increased in spending that is presenting amajor boost to the biomedical sectors. Health-care spending is expected to reach $600 billionby 2015 according to Medical Device Daily. Thisrecent advancement in medical products hascaused a blossoming of personal healthcare inChina.

Healthcare reform seems to be a hot topic inthe world today. The U.S. is not the only coun-try undergoing a healthcare reform process.Many changes have been implemented thatwill drastically alter the healthcare landscapeof China. For example, two years ago, the StateCouncil in China allocated $125 billion to im-plement the New Medical Reform Plan to ex-pand China’s services to improve universalhealth care for China’s population. Major com-ponents of the plan include efforts to expandmedical infrastructure such as restructuringexisting urban health centers and clinics andimproving new ones. These implementationswill help reform China’s healthcare system tobecome a source of innovation rather than abase for outsourced and dated biomedicaltechnology. With these renovations, patientswill be able to refocus their spending on dis-ease prevention and health improvement. Be-cause of the high demand for health screen-ing within the middle class, one area oftremendous growth is the In Vitro Diagnostic(IVD) market. Hospitals have adopted advancedtechnologies in this area, causing more private

laboratories to emerge. Another area of no-ticeable growth is in the Health InformationTechnology (HIT) sector which is expected tospend $4.1 billion by 2013. Moreover, patientswill have a greater awareness of health andwellness, leading to increased demands forhigh-quality care. As for clinicians and high-tech companies, there has been a surprisingincrease of interest in patient monitoring de-vices. For example, numerous domestic 24-hour ECG Holter Monitoring systems surpris-ingly mushroomed in China InternationalMedical Equipment Fair last year to meet theescalating demands.

The recent advancement for heatlhcare andmedical devices has already provided a majorlift to the biotechnology sector. China’s SFDAintroduced nearly one hundred new industrialstandards in December 2010, which will be-come integral parts of the medical device re-quirements beginning in mid-2012.

Several special regions in China have alreadyrewarded the desired environment for the de-velopment of biomedical products: BeijingZhongguancun Life Science Park is an area ded-icated to supporting new discoveries in ad-vanced pharmaceuticals and medicines; Shang-hai International Medical Zone specializes indevice manufacturing, R&D, medical treatmentand education; Taizhou Medical High-Tech In-dustrial Development Zone, with the supportof the central government, focuses on scientif-ic research in the manufacturing of medicalequipment.

Among a mass influx of innovative medicalproducts, the IVT Mobile Health Managementand Rescue System has gained a lot of atten-

tion, and is a distinctly successful device. Thesystem was chosen as one of the Top 10 Tech-nologies at CES 2010. As a complete remotemedical monitoring solution that allows med-ical monitoring from home, this device fullyadopted most advanced Bluetooth technolo-gies, reduces the risk of chronic diseases andassists with speedy rescues in the case of emer-gencies. Patients are able to measure blood pres-sure, cardiogram, and blood oxygen and glu-cose levels with the use of the mobile phone,wireless blood pressure meter, oximeter, glucosemeter and other devices that come with thesystem. These signals are displayed on thephone, automatically tracked on the remoteserver, and sent to third parties through mes-sages for convenient monitoring.

As a foremost global supplier of Bluetooth soft-ware, Fixed-Mobile Convergence terminal solu-tions, and location-based marketing systems,IVT’s major product Bluetooth V4.0 High Speed

has a user installed base over 100 million in 145countries. The company applied its advancedBluetooth technology, integrated various phys-iology measurement devices, and created a mo-bile health management and rescue systemtargeted to treat elderly people who suffer fromchronic diseases such as cardiovascular diseases,hypertension and diabetes.

The main device kit includes a S120 mobilephone, a wireless blood pressure meter, a wire-less ECG monitor, a wireless oximeter, a wirelessglucose meter and a wireless PSTN access point.The S120 is the first mobile phone that utilizedFixed-Mobile Convergence technologies. It canbe used as a cordless phone to make it moreconvenient when making or receiving fixed line

FURTHER AFIELD:Personal Healthcare Blossoms in China

By Lingjun Kong

“Healthcare reform seems to be a hot topic in the worldtoday. The U.S. is not the only country undergoing health-care reform process. Many changes have been imple-mented that will drastically alter the healthcare land-scape of China.”

calls. Using this set of fully automated devices,a user can measure their blood pressure, reviewtheir cardiac activity, blood glucose level andblood oxygen level. The results, which stand forvital life signs, are displayed on the S120 andsent to the user’s Personal E-Health Record ona remote server where the data is saved and an-alyzed in real time. In addition, the companionmHealth software has also been ported to Win-dows Mobile, Android and Symbian platforms,so that users will be able use their own smartphones to monitor their health condition.

The Personal E-Health Record is an online net-work platform of user health information; hos-pitals, emergency centers, or users can remote-ly access it. Emergency centers are able to usethis record system to provide better rescue plansas all of a user’s information can be accessedbased on an incoming caller ID from the S120

mobile phone. Similarly, hospitals can accesstheir patients’ E-Health Record through this ID,giving doctors a better and more comprehen-sive understanding of their patients’ health his-tory through the touch of a button.

Finally, a national level call center provides 24-hour services with health consultants who caneasily process any emergency rescue informa-tion and immediate assistance sent by theclients’ mobile device. In the case of emergen-cies, the patient can press a hotkey on the S120to connect to the emergency center. A short res-cue request with the location of the user is sentto all related parties including the IVT call cen-ter, emergency center, and relatives.

These diverse devices and software systems of-fer just a small representation of the emergingtechnologies. Although there will be harsh com-

petition and a whole different set of new rulesand regulations to adhere to for the biomedicalsector companies, China will have many noveland innovative technologies in personal health-care products in the future, even surpassing thesuccess of the IVT Mobile Health Managementand Rescue System. New opportunities are con-tinuing to grow with the planned budget allo-cations and implementation of specialized man-ufacturing and R&D research zones. WithChina’s already strong and established founda-tion in healthcare, the time is ripe for these tech-nologies to fully blossom and come to fruition.


FURTHER AFIELD

Lingjun Kong, PMPVirtual Reality Medical [email protected][ ]

Figure: IVT Mobile Health Management & Rescue System Solution. Source: Tim Wei of IVT Corporation

49

Therapeutic and EducationalUse of the Robot KASPARwith Children with Autism

50Throughout the years, psychologists, ther-apists and educators have emphasized theimportant role of play in child develop-ment as a crucial vehicle for learningabout the physical and social environ-ment, the self, and for developing socialcognition and social relationships. Fordecades the use of computers in educa-tion has been an active area of research.In utilizing interactive devices, educatorshave seen a profound and beneficial ef-fect on how children develop and grow.In recent years, researchers have been ex-ploring the use of mobile and humanoidrobots as "toys" in playful interactions forthe education and therapy of children withautism.

Studies into the behavior of children withautism suggest that they show a prefer-ence for interacting with objects ratherthan with other people. Often, childrenwith autism are described as socially iso-lated, ignoring other people near them.People’s social behavior can be very sub-tle and could seem, to those with commu-nication problems and a deficit in mindreading skills, widely unpredictable. Thiscan present itself as a very confusing and

possibly stressful experience to childrenwith autism. Different from human beings,interactions with robots can provide a sim-plified, safe, predictable and reliable envi-ronment for these children. Interactionwith the robots could be an intermediatephase where robots, with specific pro-grammed behavious and specific play sce-narios could then become social media-tors – encouraging the children to interactwith other people (peers and adults).

In this article we present case-study exam-ples from our work with our humanoid ro-bot KASPAR in several projects, e.g. AURO-RA and ROBOSKIN where the researchfocuses on ways that KASPAR can be usedas a social mediator and engage autisticchildren in various interactive activitiessuch as turn-taking, joint-attention andimitation games, with the aim of encour-aging basic communication, tactile and so-cial interaction skills.

KASPAR, a child-sized minimally expres-sive robot that was developed by the Adap-tive Systems Research Group at the Uni-versity of Hertfordshire, has a novel designparticularly suitable for social and health-

care robotics applications. It acts as a re-search platform and as assistive technol-ogy for our work with children with autism.It uses mainly bodily expressions (move-ments of the head, hands, arms), facial ex-pressions, and gestures to interact with ahuman. Aesthetic consistency and reduc-tion in details of the face are key designissues, as well as the robot’s minimally ex-pressive abilities and the recent additionof sensitive skin that are key to engagepeople in interaction.

An emphasis on the features used forcommunication allows the robot to pres-ent facial/gestural feedback clearly e.g. bychanging orientations of the head, mov-


By Ben Robins & Kerstin Dautenhahn

Figure 1: KASPAR the robot.

FEATURES

“KASPAR was found to be very attractive to children with autism andmay address some of the difficulties that these children face.Interaction with KASPAR is a multi-modal embodied interactionwhere the complexity of the interaction can be controlled, tailored tothe need of the individual child and gradually increased.”

ing the eyes and eyelids, moving thearms, and "speaking" in simple, pre-recorded sentences. A reduction in detailde-personalizes the face and allows theinteraction partner to project his/her ownideas on it and make it, at least partially,what they want it to be. These are verydesirable features for a robot to be usedin different social and healthcare appli-cations, e.g when used in assistive tech-nology with children with autism, whogenerally have great difficulties in recog-nizing complex facial and gestural expres-sions.

In recent years we have worked with sev-eral special education schools. The chil-dren varied widely in their abilities andneeds (from very low functioning chil-dren with autism to high functioning andthose with Asperger syndrome). KASPARwas found to be attractive to all thesechildren regardless of their abilities. Dur-ing this time play scenarios have beendeveloped taking children’s specificstrengths and needs into considerationand covering a wide range of objectivesin children’s development areas (senso-ry, communicational and interaction, mo-tor, cognitive and social and emotional).

Observation analysis of play sessions ofchildren with autism at schools showed

many case study examples of possible im-plementation of KASPAR for therapeuticor educational objectives as follows:

• promote body awareness and senseof self,

• help to break the isolation for somechildren,

• mediate child-child or child-adult in-teraction,

• help children with autism managecollaborative play,

• use by therapists as a tool to teachturn-taking and other basic social skills

• help to encourage or discourage cer-tain tactile behavior during child-robottactile interaction.

KASPAR Promotes Body Awareness

All the children with autism who met KAS-PAR for the first time (children of differ-ent age groups and of both genders) weredrawn to explore him in very physicalways (see Fig. 1). Tactile exploration is im-portant to increase body awareness andsense of self for these children.

KASPAR Helps to Break the Isolation

Several children with severe autism whohave very limited or no language at all,and who often are withdrawn into theirown world, got excited in their interac-tion with KASPAR and sought to share thisexperience and communicate (in a non-verbal way) with other people. One exam-ple is Liroy (Fig. 2) who is known at schoolto not interact at all on his own initiativewith other people (not with teachers, nor

with other children). After playing withKASPAR for several sessions he sought toshare his excitement with his teacher andalso started to communicate with anoth-er child and with his teachers.

KASPAR Helps Children with Autismto Manage Collaborative Play

The use of a remote control, the simpleoperation and the minimal expressive-ness of KASPAR are all encouraging as-pects for the children, not only to playwith the robot, but to initiate, control andmanage collaborative games with otherchildren and adults (Fig. 3). In this sce-nario the children no longer merely fol-low instructions of games given to themby adults (which is often the case in class-room settings) but they have the oppor-tunity, with the use of the remote con-trol, to actually manage the gamethemselves i.e initiate, follow, take turnsand even have the opportunity to give in-structions to their peers.

Autism is a spectrum disorder that canoccur to different degrees and in a vari-ety of forms. KASPAR was found to bevery attractive to children with autismand may address some of the difficul-ties that these children face. Interactionwith KASPAR is a multi-modal embod-ied interaction where the complexity ofthe interaction can be controlled, tai-lored to the need of the individual childand gradually increased. KASPAR may beused in therapy or education to encour-age social interaction skills in childrenwith autism, potentially assisting the chil-dren in generalizing experiences frominteraction with the robot to interactionwith people.

[ ]Ben Robins, Ph.D. [email protected] Dautenhahn, Dr. rer. nat [email protected] of HertfordshireU.K.

www.aurora-project.com, www.roboskin.org


51

Figure 2 (above): Liroy communicatesin a non-verbal way with another child.

Figures 3 (above):KASPAR mediateschild-child and child-adult interactionsin turn-taking and imitation game.

After being forced to completely rebuild their health-care system while at the same time strengthening theentire country around the middle of the last century,Poland has faced great obstacles to providing its popu-lation with reliable mental healthcare. Currently, Polandis giving priority to psychology programs and imple-menting new technologies to aid treatment.

[ ]C&R in Poland

ince the German occupation ofPoland beginning in 1939,Poland has been rebuilding itshealthcare system. This occu-

pation proved to be a major setback asthe Nazis first targeted psychiatric in-patients in hospitals – a huge numberperished during this time – and the ex-isting medical system was dismantled.As the country attempted to rebuild itshealthcare system in 1945, psychiatrywas not a high priority. In the 1950s itwas discovered that there was a largedef icit in the number of psychiatricbeds in central Poland, resulting in thetransfer of patients in need to westernPoland where medical treatment couldmore easily be ensured. This quick-fixsolution proved to impose stress onfamily ties and weaken relationships.Also, a lack in the number of availablestaff meant that adequate care was notalways received and it was diff icult toarchive related data that would be ofinterest for long-term studies, includ-

ing the prevalence of mental disorders.This further compounded the problemof adequately treating chronic mentaldisorders.

Rebuilding Foundations

In 1952, a special act was introducedby Parliament resulting in the creationof a comprehensive, f ree generalhealthcare system including in- andout-pat ient psychiatr ic services. Togenerate a higher number of new spe-cialists in the f ield of medicine, stu-dents were given the option to receivefree training to become physicians.Seven universities quickly establishedmedical facult ies and this , in turn,helped to develop available psychiatricservices.

The introduction of the Mental HealthProgramme and the Mental Health Actin the mid-1990s acted as momentouscatalysts to improve the future of psy-

chiatric practices in Poland. Clinical psy-chology and psychiatry have been rec-ognized as major specialties in the fieldof Medicine since 1999, with medicalstudents encouraged to enter availableprograms. Currently, 18 universities of-fer psychology programs.

Possible Limitations

The structure fund budget allocatesfunds in Poland that go towards mod-ernizing and setting up research facili-ties. Funds are accessible on a nation-al and regional level and contributetowards creating University facilities,Centers of Excellence and TechnologyParks based on multi scale domains. Re-search facilities, therefore, will be pos-itively af fected for the upcoming 2-3years, but researchers voice concernover what it will mean for the develop-ment of such facil ities and for theirstaff after the current funds are deplet-ed. An insuff icient level of national

S

> COUNTRY FOCUS


52

AUTHOR:

Emily ButcherManaging EditorC&R Magazine

[email protected]

38.2

61%

8.5%

75.7

1.3

8.5%

14.9

6

83.2

347.8

86.6

889.5

38.9

18

Population (Million)

Life Expectancy (Years)

Fertility Rate

Population Median Age (years)

Percentage of Urban Population

Unemployment Rate

Suicide Rate (per 100,000)

Psychiatrists (per 100,000)

Psychiatric Hospital Beds

(per 100,000)

Extrapolated Prevalence to Schizophrenia

(per 100,000) - Inpatient Care

Extrapolated Prevalence to Schizophrenia

(per 100,000) - Outpatient Care

Extrapolated Prevalence to Anxiety

Disorders (per 100,000) - Inpatient Care

Extrapolated Prevalence to Anxiety

Disorders (per 100,000) - Outpatient Care

Number of Universities Offering

Psychology Programs 53

> COUNTRY FOCUS

funds for already existing facil itiesmeans new growth will be slowed, per-haps offering a chance for self-financesystems or other methods to be ex-plored.

Current Projects

Many opportunities are available forPoland to participate in internationalcollaboration with countries around theworld, and in bilateral programs with theU.S. Polish scientific centers have part-nered with leading foreign centers toimplement join research projects andexchange personnel. For example, TheDepartment of Psychiatry and CombatStress of the Military Medical Institutein Warsaw (DP&CS MMI) currently col-laborates with the Virtual Reality Med-ical Center in San Diego, as well and theVirtual Reality Medical Institute (VRMI)in Brussels, Belgium to further treat-ment for stress-related disorders. Theorganizations have shared software and

related hardware, and VRMI representa-tives have assisted in personnel train-ing to use the systems in Poland. Simi-larly, the Biological ThreatsIdentification and Countermeasure Cen-tre of the Military Institute of Hygieneand Epidemiology and the Institute ofElectro-Optics of the Military Academyof Technology, centers in the PolishArmed Forces, work closely with inter-national labs.

In particular, Universities and large re-search organizations benefit from theserelationships, whether in the form of fi-nancing possibilities or furthering busi-ness ties. In particular, the 7th Frame-Work Programme set up by theEuropean Commission allows Polishpartners to fully participate in the Eu-ropean Research Area (ERA) and explorecutting edge technologies and researchpossibilities with other labs and coun-tries. This program and other types ofcollaboration allow Polish participants

to implement new technologies in theireveryday work and further collaborationfor learning and development opportu-nities.

Applied ICT Research in Poland

Advanced technologies are gradually be-ing adopted into current practices. TheDP&CS MMI is the first organization touse Virtual Reality (VR) technology inthe prevention and treatment of men-tal disorders. “We have been successful-ly using this technology in a compre-hensive therapy of fear disordersconnected with combat stress experi-enced in military operations in Iraq (Op-eration Iraqi Freedom – OIF) andAfghanistan (International Security As-sistance Force - ISAF),” said Prof. Dr.Stanislaw Ilnicki, a leading researcherin the program.

Information and Communications Tech-nology (ICT) research will assuredly play

C&R in Poland


a large role in the development ofPoland’s treatment of mental healthproblems in upcoming years. A rap-idly growing market will include mo-bile solutions, including telemedi-cine, to provide easier access tomultimedia medical records formedical staf f as well as patients.Adam Koprowski, a General Special-ist for Telemedicine Developmentat the Warsaw Military Instituteagrees that eHealth is a boomingindustry including diverse applica-tions such as the implementationof complex Hospital InformationSystems, as well as telemonitoring,sensoring and intell igent homesand buildings.

Additionally, the elderly populationin Poland, s imilar to the trendthroughout other developed coun-tries, will continue to grow, whichwill lead to a growth in healthcarefaci l i t ies and implementing ICTtechnology as needed. These pop-ulations in particular may benefit

from tele-rehabilitation to managechronic diseases through the de-l ivery of specia l ized servicesthrough the Internet, such as aneasily accessible software platformto aid in interaction between hos-pita l personnel and at-home pa-t ients during the rehabi l i tat ionand monitoring processes, Ko-prowski says.

Spojrzenie Do Przyszłości

As has already been established,the use of ICT in the area of men-tal health protection in the PolishArmed Forces wi l l be appl ied inthe psycho - and socia l suppor tnetwork as well as long-term mon-itoring of veterans’ quality of life.The application of VR therapy willundoubtedly see further supportand growth and I lnicki says, “Weare going to continue to developappl icat ions of VR in therapy ofwar-trauma related fear disordersand in stress-resistance training.”

Lastly, in 2010 the Military Instituteof Medicine in Warsaw (WIM) initi-ated a permanent tele -medicinecommunication project with theISAF’s healthcare service which willbe used for both psychiatric andpsychological consultations.

Poland has suffered largely since themiddle of the 20th century, but hasdeterminedly built a strong founda-tion for a competent and competi-tive healthcare system. Through in-ternational collaboration and thevisions of talented Polish re-searchers and caregivers, healthcarewill continue to improve and gainstrength, aided largely by advancedtechnologies.

54

> COUNTRY FOCUS

Sources:

Personal communication with Adam Ko-prowski and Stanislaw Ilnicki, M.D., TheBritish Journal of Psychiatry, and WorldHealth Organization

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