Use of technology in Rehabilitation

Use of technology in RehabilitationMS Trust ConferenceMonday 7th November 2016

Start by saying not an technology person. Physiotherapy researcher work my smart phone and pass most things to my teenagers. Work in team with computing science, social science, exercise science, medics etc1

Who has a smart phone?Who has a IPad/android tablet?

Who uses technology in their practice?What technology do you use?

Quick questions

Technology is everything from telephone conversation, assistive technology, 2

Overview of technology in RehabilitationBarriers and DriversConsider neurophysiological/scientific basisLook at some examplesRoboticsMobile and digital technologyGaming and Virtual RealityInteractive session/DiscussionPlan for workshop

Look at examples they is a lot of overlap, not mutually exclusive3

Delivery of Rehabilitation

Rehabilitation

Recognises complexity of neurological conditions including MSEmerging scientific basis (neuroscience, neuroengineering, neurotechnology)Based on principles of neuroplasticity, motor learning/ relearning, High intensity, repetitive, task specific practiceBehaviour change principlesGenerally repetitive, boring, nonmotivating, issues with long term adherence

Neurorehabilitation

Should be based on same sound scientific principlesMuch of the evidence base in strokeMany commercial products without sound evaluation/evidenceTechnology can provide controlled, repeatable, intensive, interactive, motivating rehabilitation with feedback to the person and therapist

Technology in neurorehabilitation

High benefit/risk ratioInvolvement of therapist into the patient/technology loopTransparent human-machine interface (technology as artificial intelligence as a support for human intelligence) (Morone et al 2016)

Technology in neurorehab (2)

CostRemunerationConfidentialityGovernanceTechnologySkills (staff and pts)AttitudesChallenge on roleScope of practiseRecord keeping

Increased demand on servicesLife long rehabilitationUnable to accessconventional treatmentEffort outweighs benefitsTiming (pt and therapist)Cost of travelAccessibilitySeen by an expertGrowing evidence baseBoring

DRIVERSBARRIERS

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Exoskeletons, one and two arm robots, joysticksMainly upper limb and in strokeWhole limb or individual segmentsImproving in terms of degrees of movement possible especially around the shoulderOften combined with virtual realitySimilar cost to intensive rehab but preferred by patients (Housman et al)Robotics

Probably emerging area. Lots of robots on TV eg honda robot, Confused.com robot (Called Brian), robot for vaccuming, cutting the grass etc10

VR involves the simulation of an environment with which the patient can interact. Varies from immersive VR systems (headsets) to simple games on computer screenProbably used most in ExergamesVirtual reality (VR)

Principles of VR based on sensory-motor practice, adaptive learning, modulating brain reorganisation through visual, somatosensory and auditory feedbackImproves motor learning via watching own avatar

In upper limb rehab VR can be combined with instrumented gloves with sensors, accelerometers, vibration etc for haptic feedbackVirtual reality (2)

Pros and Cons of VR systemsProsConsIncreases motivation and possible distractionSome cheap home based options eg WiiCan provide natural situations (shopping) or distorted realityStudies show better or similar results to conventional rehab but greater adherenceEvidence of improvement in eg. arm movement, balance, walking

Not clear if exercise is at sufficient intensity for health benefitsNo consensus on duration/frequency/games etcNot specific to needs of people with MSNovelty might wear offLimited evidence base currentlyCost?

Massetti et al (2016) VR systematic review

Use hand held controllers or body movement on a balance board to control game playNot specific for rehab so some games/feedback to users not so appropriateBalance board might be a trip hazardSafe and feasible Low costPossible home useSupervised or unsupervisedWii Virtual Reality

Robinson et al (2015)- 4 weeks of twice weekly training improved postural sway (balance) similar to conventional rehab but more motivating

Pau et al (2015) 4 weeks of home programme (Penguin Slide, Table Tilt and Balance Bubble), improvements in balance in ML direction only

Prosperini et al (2014) reported microstructural improvements in superior cerebellar peduncles following 12 weeks of 5x week Wii Fit training, corresponding with improved clinical balance(improvements lost 12 weeks post intervention)

Other Refs: Plow and Finlayson (2011), Nilsaragd et al(2013), Brichetto et al (2013), Prosperini et al (2013)

Wii (cont) Evidence base

Microsoft Kinect- Virtual Reality Relatively cheap and convenient for homeUses cameras and depth sensors Bespoke software can be developed Also possibility of physio seeing if exercise being performed correctlyUses human form avatars

Kinect (2)Lorzano-Quilis et al (2014) developed RemoviEM using the Kinect. 3 games (touch ball, take ball, step ball). 6 people with MS, 10 one hour sessions, once a weekResults improvements in BBS, Anterior Reach test, also good acceptability and safety

Computing Science U/G student project

Virtual reality applicationHardware: Leap Motion ControllerSoftware: Game Engine - Unity3D + Leap Motion API

The LMC tracks the positions of a users hands. It can track two hands at the same time with an accuracy of up to 0.01mm and up to 300 frames per second. The LMC employs 3D optical sensor technology based on stereo vision. It consists of three Infrared LEDs (light emitting diodes) and two IR cameras Costs about 40

Leap Motion Controller

Leap motion - VR

Any Questions?

Mobile and digital healthTelerehabilitation

Evolution of mobile technology

World RegionsPopulation2016 Est.InternetUsers 2016Penetration Rate %AFRICA1,185,529,578340,783,34228.7 %ASIA4,052,652,8891,846,212,65445.6 %EUROPE832,073,224614,979,90373.9 %MIDDLE EAST246,700,900141,489,76557.4 %NORTH AMERICA359,492,293320,067,19389.0 %LAT AM / CARIB626,054,392384,751,30261.5 %OCEANIA / AUSTRALIA37,590,82027,540,65473.3 %TOTAL WORLD7,340,094,0963,675,824,81350.1 %

Internet usage (2016) 86% of the adult population of the UK used the internet73% (36 million adults) used it on a daily basis (Office of National Statistics 2013)More people in the UK use the internet than have a carMore people have a mobile phone than a toothbrush

Telerehabilitation is use of information and communication technologies as a medium for the provision of rehabilitation services to sites or patients that are at a distance from the providerTelerehabilitation has advantages for those who have problems travelling, who work or are carers, who live remotelyfor whom the effort of coming to the clinic outweighs benefitsMobile and digital technology(telerehabilitation)

Why did we start doing this work? We had been running exercise classes in the community for people with MS were very aware that people often couldnt access the class

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Wide range of activities from telephone conversation to immersive VRMajority of studies in MS were internet based interventions but also phone basedGenerally methodologically weak and heterogeneous studies Overall low evidence for short term gains in functional ability (PA, balance and posture) and fatigues as well as psychological adjustment and QOL.Evidence is lacking(Systematic review - Amatya et al 2015)Evidence for telerehabilitation in MS

Scoping - Internet usage in MS In 2010, the Multiple Sclerosis Society undertook a survey of its members to inform their Web Accessibility Policy (v1.0). 92% used the internet three times or more per week only 20% had problems in using the internet. visual and dexterity problems were most commonly reported generally no modifications or access technologies were required (many increased the font size).

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586 people with MS in Germany (mean age 41 +/-10) years95.2% had access to a computer70.8% used it daily96% had a mobile phoneWhen asked what forms of communication from HCPs were acceptable 20.5% internet or SMS, 41% website, 54% emailPeople who used technology more likely to find new technology acceptable(Hasse et al 2012)

Use and acceptance of electronic communication in MS

webbasedphysio.com

Use an external web design/hosting companyLots of issues bought web based physio.co.uk used in NZ to changed to webbasedphysio.com then realised .com domains were blocked by our local NHS providersLots of coproduction with people with MS28

The website has 2 sections1) exercise pages; each page has a video clip, written description, audio explanation of each exercise, timer and exercise diary2) information/advice section

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Patients are assessed face to faceGoals agreed Physio selects exercises appropriate for the patients programmePatient logs in at home to see their individualised programme

Patient Perspective

Physiotherapist PerspectiveWhen patient completes their exercise they tick the box and can leave comments for the physio

Physiotherapist PerspectivePhysio can change/progress the programme with two clicks

Participants30 people with Multiple Sclerosis and EDSS 5-6.5

Intervention (n=15)-12 weeks of twice weekly, web-based exerciseWeekly phone calls from physiotherapistRemote alterations in programme as required Control (n=15) - Usual carePilot study

Variable/GroupPreMean [sd]PostMean [sd]MeanDifference[Pre-Post]95%ConfidenceIntervalEffect SizeCohensd25FWControl0.91 [0.45]0.91 [0.43]0.00-0.06, 0.060Intervention0.75 [0.36]0.80 [0.36]-0.05-0.13, 0.020.44BBSControl43.86 [12.71]44.21 [11.82]-0.36-1.78, 1.070.03Intervention40.80 [14.79]42.07 [13.36]2.29-3.13, 7.720.09TUGControl17.01 [8.11]15.10 [5.37]1.91-0.05, 3.870.28Intervention26.61 [27.84]24.32 [21.85]2.29-3.13, 7.720.09MS SymptomControl34.14 [17.27]32.64 [13.85]1.50-3.94, 6.940.10Intervention37.07 [11.93]32.00 [13.58]5.07-0.55, 10.680.40MSIS-PHYControl43.04 [20.87]40.98 [20.44]2.05-6.04, 10.150.10Intervention48.42 [15.83]39.83 [19.87]8.590.09, 17.070.48MSIS-PSYControl34.32 [22.48]28.77 [16.97]5.56-2.62, 13.730.28Intervention35.74 [17.12]29.44 [17.56]6.30-1.83, 14.420.36HADS-AControl6.43 [4.11]4.50 [2.79]1.930.42, 3.440.55Intervention5.80 [3.88]5.87 [4.05]-0.07-1.16, 1.030.02HADS-DControl6.07 [2.62]5.79 [3.26]0.29-0.79, 1.340.10Intervention5.73 [3.73]5.67 [2.90]0.06-1.20, 1.330.02LEEDS QoLControl11.71 [3.60]10.71 [4.53]1.00-0.54, 2.540.24Intervention10.13 [4.52]10.20 [4.71]-0.07-1.67, 1.530.01

Results - quantitative

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Results - qualitative

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Multi-centre feasibility study (NHS Ayrshire and Arran, NHS Lothian, PlymouthFunded by the MS Society90 people with MS have been recruited6 months of WBP and 3months follow upStart to look at cost as well as clinical effectivenessDue for completion December 2016New study in Saskatoon, CanadaWhats happening now?

So this should be the last time I present the pilot data we should have results of this larger trial next year including some basic health economic evaluation.

Ongoing work in other LTCs36

http://www.webbasedphysio.comemail address mstestphysiopatient@gmail.compassword: password

Paul L, et al (2014) Web-based physiotherapy for people moderately affected with Multiple Sclerosis; results from a randomised, controlled pilot study and the patient experience Clinical Rehabilitation 28 (9) 924-935

Demonstration Page

STARFISH, a facilitated, behavioural change programme to encourage physical activity, delivered via a mobile phone app

STARFISH is a smart phone app designed as a behavioural change intervention to encourage physical activityThe sensors within a standard smart phone record the number of steps taken per day by the individualEach person is represented by a fish within a fish tank. When the participant is active their fish blows bubbles and swims faster As the participant reaches their target number of steps per day, their fishs fins and tail grow.STARFISH

STARFISH is undertaken in groups of fourEach fish is distinguishable by colour thus each participant gets feedback on the activity of each member of the group Each person can access their daily or weekly step counts

Key features Social Facilitation and Targets

Each week the fish fins grow if the person achieves their daily targetPhysical activity targets are individual Individualised feedback for motivationIf individual reaches their step count target it is increased (by 5%) for the following week

Physical activity targets - Individual

Each week a new creature comes to swim in the tank if the group achieve their target on 5 of 7 days in the week (seahorse, octopus, final creature is a Starfish)Group reward for motivationPhysical activity targets - Group

16 older people 6 week interventionOutcome measures: Step/day, BMI, blood pressure, HR, functional measures, blood lipids, LFTs, CRP, HBA1c 32% increase in steps/day Technological challenges ++One broken leg (fall)

STARFISH in Older People

First study we did43

24 people after stroke (4.2yrs) 16 intervention/8 controlFollowed STARFISH app for 6 weeks

physical activity, sedentary time, heart rate, BP, BMI, Fatigue Severity Scale, Instrumental Activity of Daily Living Scale, Ten Metre Walk Test, Stroke Specific Quality of Life Scale, Psychological General Well-Being Index.

Starfish in stroke

44.6% increase in steps/dayWalking time increased (p=0.002) Fatigue reduced significantly(p= 0.003)

STARFISH is a fun way to improve physical activity and health outcomes in people after strokeFocus is on number of steps not quality of gait pattern or the intensity of activity

Discussion

In stroke Currently undertaking larger RCT 128 people following stroke randomised to 4 months of STARFISH or usual care Two different backgrounds (2 months each) and different creatures/rewardsFatigue After Stroke Study (FASS): A physical activity intervention Melbourne, Australia (Toby Cumming)In breast cancer survivorsIn overweight women in Bahrain (Orla Merrigan)In people with MS????Other STARFISH projects

http://www.webbasedphysio.com email address mstestphysiopatient@gmail.compassword: password

Lorna.Paul@glasgow.ac.uk0141 330 6876

Demonstration Page

ThemesSubthemesIndicative quotes

Using of the WebsiteEase of usepretty easy and straightforward wbp1not the best person on the computer but I did manage wpb2

Using the programme if I have had a really tiring day I pick out certain ones... then at least I am doing something, rather than nothing wbp8

Suggested improvementsAbility to review previous diary entries would have given an indication if I was feeling better one day than the other at doing the exercises wbp10

Physical and psychological changemy walking got a lot better wbp5 it opened my eyes to what I can do and its made me a bit more confident wbp10

Web-based physiotherapy as a mode of deliveryEnjoymentI enjoyed doing it wbp10I enjoyed it the way it was wbp1

Practical convenienceI dont have to get dressed, get my jacket on and go in the car wbp1it was a better option for me to do the exercises at home because I dont drive any more and I would be relying on my poor old dad to drive me wbp9

Exercising aloneIve went to a couple of classes since I had my MS, its quite embarrassing sometimes because you cant do... in my own home I didnt have the embarrassment factor wbp10

Supported exerciseI knew I could phone her [the physio] or text her, or mention it in the diary... it was all the support that you would want wbp13

Future plans I have went and joined the local gym wbp10