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Technology Related Research @ Bruyère
Continuing CareFrank Knoefel
Jeff JutaiHillel Finestone
2012/06/14
Bruyere Continuing Care: BIGR Rounds
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Objectives
1. Describe three of the main areas of focus for technology research at Bruyère
2. Explain how technology can help improve the quality of care at Bruyère and quality of life of patients
3. Identify opportunities for participating in technology research at Bruyère.
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OUTLINE
• Background– Technology review– Evidence it works– Assistive technology framework
• Assistive Technologies Research Lab• Virtual reality in stroke rehabilitation• TAFETA
– Nocturia, nutrition, breathing, transfers
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Aging Population vs. Services
• The number of older Canadian adults (65+) is projected to increase from 4.2 million to 9.8 million between 2005 and 2036.
• Between 2005 and 2020, the ratio of older Canadians to the labour force (15-64 years) is expected to rise from 25% in 2005 to 52% in 2020
• Aging in Place strategy• Canada will be short +/- 60K FTE RNs by 2022
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Communication Tech Changes
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Merchandise Tech Changes
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Healthcare Tech Changes?
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Evidence
OTN Telehomecare pilot program launched in March 2007
• provides care and monitoring to patients with– congestive heart failure (CHF)– chronic obstructive pulmonary disease
(COPD)
• over 800 patients enrolled
• largest Telehomecare program in Canada
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Evaluation of Telehomecare Program
• Evaluated by PriceWaterhouseCoopers through survey tools
• Showed reduction of– 65% (avg #) of hospital admissions– 72% (avg #) of ER visits– 95% (avg #) of walk-in clinic visits
Ontario Telemedicine Network 2009 Annual Report
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Gerontechnology FrameworkLIFE DOMAIN
GOALHealthSelf-esteem
Housing Daily living
MobilityTransport
CommunicationGovernance
WorkLeisure
EnrichmentSatisfaction
- self care- software personalisation
- interactive controls- teleservices- eShopping- adaptive control
- eBicycles- navigation tools- Info public transport
- mobile phone- e-mail- e-info- multimedia- e-learning- touch screens- mouse
- digital camera- tele-games- social computing- cash dispensers- tele-banking- DVD
PreventionEngagement
- healthy diet- hip protectors- health monitoring- eHealth info
- smart ventilation- safety illumination
- car automation - noise abatement- automated messages
- work simulator
CompensationAssistance
- passive alarms- medication reminders- tele-rehab- Viagra
- cleaning robots - scoot-mobile- smart walker- navigation tools
- accommodative lens implants- cochlear implants- retinal implants- delayed speech
- garden robots- robot pets
Care support& organisation
- control PDA- carer training system- clinical GT
- electronic keys - navigation tools - video links - telecare
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At Bruyère Continuing Care, technologies are being researched that address important issues for our patients, such as, computer access, continence management, effectiveness of mobility aids, falls risk assessment, home safety monitoring, recovery following stroke, and support to caregivers.
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Technology Related Research @ Bruyère
Continuing CareAssistive Technologies Research Lab
Dr. Jeff JutaiScientist, Bruyère Research Institute,
Professor, Faculty of Health Sciences, University of Ottawa
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Current Projects
1. Nouse (nose-as-mouse): Pilot study with stroke patients (funded by BAMO)
2. Assistive Technology Outcomes Profile for Mobility (ATOP/M) (funded by National Institute on Disability and Rehabilitation Research)
3. Psychosocial impact of technologies for continence management (C-PIADS project) (funded by CIHR)
4. A multi-site randomized control trial of the impact of assistive technology with individuals with mobility limitations and their caregivers (CATS project) (funded by CIHR)
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Nouse Project
PI: Hillel FinestoneCo-I: Jeff JutaiCo-I: Hilary McKeeCo-I: Melanie CarterCo-I: Jodie TaylorProject Co-ordinator:
Jasmine Mah
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The unique, patented technology uses advanced video recognition algorithms to map the movement of the user’s nose to the movement of a computer mouse device thereby allowing a user to operate a computer hands-free.
Essentially, Nouse™ is recognized as the first technology to use the nose as the principal feature for facial tracking, a process that involves setting up a webcam on a computer equipped with tracking software.
The computer registers an image of your nose and then maps it onto the on-screen cursor, which you control with the movement of your nose. It enables the computer to track movements with dramatically improved precision over traditional methods.
Nouse™ application was developed for anybody to use, however, it will be most useful for those computer users who have difficulty using their hands to manipulate a mouse or keyboard, or for those who want to take breaks from using their hands due to fatigue/injury.
See a demonstration video of the Nouse at:
http://www.nouse.ca/Shop/
Nouse Project (cont’d)
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ATOP/M Project
PI: Jeff JutaiCo-Is: Louise Demers (U.
de Montreal), Frank DeRuyter (Duke U.), Marcus Fuhrer (NIH), Jim Lenker (SUNY Buffalo)
Aim: To investigate user acceptability and clinical efficiency of the ATOP/M
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The Assistive Technology Outcomes Profile for Mobility (ATOP/M) consists of 68 items distributed across two domains, each having two subdomains:
Activities (Physical Performance and Instrumental Activities of Daily Living);
Participation (Social Role Performance and Discretionary Social Participation).
ATOP/M yields two scores, one reflecting respondents’ mobility level while using a device, the other reflecting their capability without it.
The ATOP/M has been translated into Canadian-French, and a computer adaptive testing (CAT) has been developed.
ATOP/M Project (cont’d)
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The following are example items.
ActivitiesPhysical Performance: Are you able to get around your
neighborhood or town?Instrumental Activities of Daily Living: Are you able to do yard
work like raking leaves, weeding, or pushing a lawn mower?
ParticipationDiscretionary Social Participation: Are you able to participate
in active recreational activities?Social Role Performance: Are you able to go to classes or
participate in learning activities?
For the following questions, please use the scale below:5=Without any difficulty; 4=With a little difficulty; 3=With some difficulty; 2=With much difficulty; 1=Unable to do
ATOP/M - Questionnaire
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ATOP - Results
Results to date: Elderly mobility device users were able to
complete the computerized (CAT) version of the ATOP/M within 30 minutes. On average, only 12 items were required to obtain a reliable estimate for each of the with-device and without-device assessments.
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C-PIADS Project
Aim: To measure the impact of continence technologies on the quality of life of elderly individuals
Interviews were conducted with elderly individuals who have continence problems and their caregivers.
– To identify important areas for impact of continence technologies and what modifications and enhancements might be needed to a self-report questionnaire called the PIADS
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What kinds of products are you currently using for bladder and bowel control management? Please describe all of the different types of products you use.
What kinds of things do you do to help your bladder and bowel control management? Please describe all of the different things that you do.
In a typical day, what kinds of bladder and bowel control difficulties do you have?
What things are you able to do with your product(s) that you could not do without it/them? Are you able to do these things by yourself or do you need someone’s help?
What impact has your technology had on other people in your life (e.g., family, friends, caregivers, etc.)?
What do you like best about your current products and strategies? What positive effects do they have on your life?
What do you like least about them? What negative effects do they have on your life?
How satisfied are you with your current products and strategies?Take a few moments to think about the technology you want and need
most for managing your continence difficulties. Are there any barriers you face when trying to get and use it? Please describe.
C-PIADS - Interview Questions
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C-PIADS Project
The participants were then asked to look at the Psychosocial Impact of Assistive Devices Scale (PIADS) and say whether they thought it was missing any item that may be important for continence.
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C-PIADS - Results to Date
The PIADS seems to address most of the important psychosocial concerns of adults who have continence difficulties.
The development of a modified version for continence (C-PIADS) will require some modifications to the instructions and the addition of some new items which address stigma.
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CATS ProjectPIs: Louise Demers (U. de
Montreal), Jeff Jutai (BRI), Frank DeRuyter (Duke U.), Ben Mortenson (Simon Fraser U.), Andrew Sixsmith (Simon Fraser U.)
Ottawa Site Co-ordinator: Emily CormierIn partnership with the Champlain
District Community Care Access Centre.
Aim: To investigate an intervention that involves a detailed in-home assessment of the person's current assistive technology and the negotiation and implementation of a personal assistive technology plan with the person and his/her caregiver.
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CATS Project - Objectives
1) To determine the efficacy of this intervention for individuals with mobility limitations and for their caregivers.
2) To explore how the intervention is experienced by these individuals.
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We anticipate this intervention will 1)increase the mobility, well-being, and
satisfaction with caregiver assistance of the individuals with mobility limitations;
2)reduce the amount of caregiver assistance required; and
3)decrease the psychological demands on caregivers and increase their satisfaction with caregiving-related activities.
CATS Project – General Hypotheses
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This project is a multi-site research study. At each of the Montreal, Ottawa and Vancouver sites, we are enrolling 40 individuals with mobility limitations, and 40 of their caregivers (total of 120 dyads).
Eligibility criteria: client over 65 years of age, with a physical limitation, no evidence of cognitive deficit, and who lives with a caregiver that offers him/her at least 4 hours of care per week. Participants are assigned to either an immediate intervention group or to a delayed intervention group. Outcomes of this assistive technology treatment for individuals with mobility limitations and their caregivers are measured before and after intervention using a variety of standardized instruments.
CATS Project – Methods
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The evidence produced by this study will enable service providers to offer assistive technology interventions that are more attuned to the needs of both individuals with mobility limitations and their caregivers and enable providers to lobby for better funding for equipment and follow-up intervention services.
CATS Project – Anticipated Impact
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For further information:
Dr. Jeff Jutai [email protected]
Research lab located at:Saint-Vincent Hospital, Annex B, 3rd floor
Lab phone (SVH): 613-562-6262 x2245
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Technology Related Research @ Bruyère
Continuing Care
Virtual reality in stroke rehabilitation
Dr. Hillel FinestoneDirector of Stroke Rehabilitation Research, Bruyère Continuing Care
Associate Professor, Division of Physical Medicine and Rehabilitation, University of Ottawa
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Research Team
Dr. Martin Bilodeau, PhD
Associate Professor and Director, School of Rehabilitation Sciences, University of OttawaCo-investigator
Dr. Heidi Sveistrup, PhD
Professor and Vice-Dean, Research and Graduate Studies Faculty of Health Sciences, University of OttawaCo-investigator
Dr. Hillel Finestone
Director, Stroke Rehabilitation ResearchElisabeth Bruyère Hospital, Bruyère Continuing CareAssociate Professor, University of OttawaPrimary Investigator
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Research Team (cont’d)
Anne Taillon-Hobson
BSc (PT), MScResearch Associate, VRRASS
Dan McEwen
PhD candidate, School of Rehabilitation SciencesUniversity of Ottawa
Dr. Leo Tseng
Division of Physical Medicine and Rehabilitation University of Ottawa
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Introduction• Balance impairments (Barclay-Goddard et al., 2004)
and independent walking (Patel et al., 2000) are frequently impaired in the post-stroke population
• Balance has been shown to improve following retraining (EBRSR – Evidence-Based Review of Stroke Rehabilitation, www.ebrsr.com, 2007)
• Virtual reality (VR) exercises have been shown to improve balance in the community-dwelling TBI population (Thornton et
al., 2005) and in adolescents with cerebral palsy (Brien & Sveistrup, 2011)
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Introduction (cont’d)
• VR exercises transfer to real-world situations (Jaffe et al., 2004; Lam et al., 2006), potentially improving community-based functional activities such as walking in a risk-free environment (Lam et al., 2006)
• VR exercises can enhance family/community involvement in rehabilitation of patients (Thornton et al., 2005; Finestone, 2011)
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Introduction (cont’d)
• Laver et al. (Cochrane Database, Sept. 2011) and Deutsch (2012) concluded that future studies investigating the use of VR exercises in rehabilitation should be characterized by:– robust methodologies, including blind
and randomized protocols– the inclusion of inpatient populations
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VRRASS Project
• Objectives:1. Determine whether VR, as an adjunct
treatment, is beneficial for rehabilitation by improving balance and function in the inpatient stroke population
2. Establish whether VR exercises are safe and feasible to implement in an inpatient rehabilitation environment
3. Document stroke patient satisfaction with VR exercise programs
Virtual Reality Rehabilitation After Stroke Study
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What is Virtual Reality (VR)?
“A simulation of a real world environment that is
generated through computer software and is experienced by the user
through a human–machine interface”
(Holden, 2005)
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Methods
Treatment Group
• N = 30• Conventional
therapy + VR exercise while standing
Control Group
• N = 30• Conventional
therapy + VR exercise while sitting
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Inclusion/Exclusion Criteria
Inclusion
1. Ability to stand independently for >1 minute
2. Ischemic or hemorrhagic stroke in left or right cortical or subcortical region
3. Balance and gait deficits resulting from stroke
4. Ability to understand and follow instructions
5. Ability to provide informed consent
Exclusion
1. Severe cognitive impairments or unable to follow instructions
2. Unstable medical condition
3. Vestibular deficits or vertigo
4. Seizure activity in past 6 months
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Outcome Measures
• Berg Balance Scale and, if ≥ 48, Community Balance and Mobility Test
• Functional Independence Measure (FIM)• Chedoke-McMaster Stroke Assessment
(arm, leg, posture)• Two-Minute Walk Test• Timed Up & Go Test• Quasi-static measures (centre of pressure,
pressure mat)• Ottawa Sitting Scale
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Randomization Patient admitted to Élisabeth Bruyère Hospital and assessed for medical suitability
Suitable for the Study?
YES NO
Routine care and therapies
Primary care nurse obtains verbal consent from patient to meet VRRASS research associate
Patient contacted by VRRASS research associate who details the study to the patient and provides written information
Patient consents to participate in the study?
Consent form signed and clinical outcome measures initiated
Routine care and therapies
YES
NO
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Protocol
• Daily 30- to 45-minute sessions of which20–25 minutes are VR exercises
• 6–10 sessions• Outcomes assessed three times:
– Before training– Following the end of training– 1 month after the end of training
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Statistical Analysis
• Baseline demographics• Repeated-measures analyses to determine
significant differences in outcome measures across the three test sessions
• SPSS 17.0 software, α level of 0.05
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Preliminary Results
May 1, 2011–April 30, 2012
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Stroke Unit Patient DemographicsN = 206
104 men, 102 womenMean age: 68 years (range 21–89)FIM mean total score: 75 (range 23–114)FIM mean motor score: 55 (range 17–90)FIM mean cognition score: 20 (range 6–33)
Eligible for study?
Yes49
No157
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Eligible Participant Demographics
49 patients eligible for study
Enrolled: 38
20 men – mean age 60 (range 21–86)18 women – mean age 61 (range 26–88)FIM mean total score 93 (range 62–110)FIM mean motor score 69 (range 37–88)FIM mean cognitive score 24 (range 13–30)
Refusals/unsuitable: 11
Hate computers 2Too anxious to learn 1Not interested 7Not stroke 1
Continue with routine care and therapies
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27 active participants
23 have completed 3/3 phases4 have completed 2/3 phases
10 withdrawals
Early discharge 2Too tired 2Fear of second stroke 1Increase in cluster headaches 1Noncompliant with protocol 2Technical problems 2
38 patients enrolled
Participant Demographics
1 lost to follow-up
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Participant Demographic Features
FeatureTreatment group (n =
18)
Control group (n =
20)
Mean age (yr) 61 62
Sex Male 8 12
Female 10 8
Side of stroke Right 8 7
Left 9 11
Bilateral 1 2
Type of stroke Ischemic 15 19
Hemorrhagic 3 1
Location of stroke Cortical 14 16
Subcortical 8 13
No. of days between stroke and start of VR training
29 38
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Lessons Learned So Far
• What % of newly admitted stroke rehabilitation inpatients can stand for >1 minute?
→ likely only 20%• Balance requirement may skew
age/disability level of subjects selected• Cognition influences participation• Scheduling is critical• Most participants find it enjoyable
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Next…
• Finish recruitment• Analyse data• Submit results for publication• Apply for grant: “VR and the
Seated/Wheelchair Population”
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Questions?
Thank you!
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Role of Technology in Supporting
“Aging in Place”Dr. Frank Knoefel
Co-Lead, TAFETA project,
Clinical Scientist, Bruyère Research Institute
Technology Related Research @ Bruyère
Continuing Care
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What is TAFETA?
Technology
Assisted
Friendly
Environment for the
Third
Age
Technologie
Avancée pour
Faciliter
l’Environnement du
Troisième
Age
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TAFETA
• Multi-disciplinary team: clinicians and engineers
• Bruyère Research Institute, Bruyère Continuing Care, Carleton U, uOttawa…
• Change Foundation grant 2003 • Model apartment in 2004 • Over $1 M in grants from various agencies
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CMHC Fridge
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Fridge Use: Tri-modal
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Fridge Use: Bi-modal
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Fridge Use: Multi-modal
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Pressure Sensitive Mat
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NOCTURIA - RESULTS
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Sit to Stand - Methodology
Sample sit-to-stand sequence imagesTiming – Bouncing - Symmetry
4
Hip
RH
Hip
LHRH
Hip
LHRH
LH
Hip pressure region 1
Hip
Hip and hand pressure regions
Hand pressure regions Bed Exit Position
1 2 3
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Sit-to-stand Results - Healthy volunteer
0.5 1 1.5 2 2.5 30
0.2
0.4
0.6
0.8
1
Time (sec)
Nor
mal
ize
d P
ress
ure
HipLHRH
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0 1 2 3 4 5 6 70
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1P1269 Older Stroke-3
Time (sec)
Nor
mal
ize
d P
ress
ure
- 1
=17
429
Bed PressureShuffle
0 1 2 3 4 5 6 7 8 90
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1P1269 Older Stroke-2
Time (sec)
Nor
mal
ize
d P
ress
ure
- 1
=18
109
Bed PressureBounce
0 1 2 3 4 50
0.2
0.4
0.6
0.8
1
Time (sec)
Nor
mal
ize
d P
ress
ure
- 1
=15
110
Bed PressureUnsuccessful Transfer
1. Shuffling in the sit position
2. “Bouncing” to generatemomentum before
standing up
3. Unsuccessful transfer
Sit-to-stand Transfer - Older Adults
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Mat Intelligence
0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 50
1
2
3
4
5
6
7
8
9
group
tim
e (
s)
1=Young Healthy, 2=Older Healthy, 3=Stroke, 4=Hip
YH OH
OS
OHip
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MOBILITY - Individual over time
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Centre of Pressure Study
• For each transfer, the sagittal CP was observed over time and its deviation was measured
y y y y
x
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Centre of Pressure - Results
Healthy Mobility-impaired
Difference
Sagittal Deviation
0.48 ± 0.23 1.56 ± 0.51 p < 0.001
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BREATHING - Results
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BREATHING - Results II
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Acknowledgements
• Dr. Rafik Goubran, Dean Engineering, Carleton University, co-lead TAFETA
• Drs. Martin Bilodeau, Jeff Jutai, Heidi Sveistrup
• Stéfanie Rocan, Project Manager• Numerous learners: Health and Engineering
• CIHR, NSERC, CMHC, Sens Foundation
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Questions?