Innovating Solutions in Telerehabilitation
Cody Wolfe; Ubaid Murad; Aleks Borresen; Yuan Tian; Balakrishnan Prabhakaran, PhD; Thiru Annaswamy, MD
As a branch off the larger telemedicine movement, telerehabilitation has sought to bring remote rehabilitative care directly to patients. It has come a long way since its birth over phone calls and video chat, and has grown to incorporate complex machines and computer programs. Notable developments include the use of virtual environments and haptic machines to create interactive, at-home rehabilitation environments, and the “gamification” of these technologies to make the treatment more engaging and fun for the patient.
Virtual Reality and Haptic Technology in Telerehabilitation
Some challenges and barriers with traditional rehabilitative exercise therapy include poor patient engagement and motivation. Adherence to prescribed home exercises can suffer as a result. Virtual reality is one way for providers to use telerehabilitation to improve patient motivation and adherence to exercise programs. Virtual reality can be described as a communication technology that allows for immersion in, and interaction with, a computer-generated environment. These environments are created to be fun “places” in which patients can continue their rehabilitation, with the added benefit of allowing providers to accurately monitor patients and provide feedback in real time. Data can be collected in these programs that can then be used to more appropriately tailor the therapy to each patient. Additionally, commercial sensors — such as those found in the Microsoft Kinect or Nintendo Wii balance board, for example — allow for remote measurements to be collected, making such technology much more valuable. The software solutions that work with such hardware are increasing in number, making it easier for clinicians to contribute to research and utilize the technology in their practices.
The success of virtual reality use in telerehabilitation therapy has been compounded by the integration of haptic machines. This technology extends a patient’s interaction with the virtual environment through the sense of touch, allowing the user to manipulate the environment and allowing the environment to provide force feedback to the user. This addition can improve exercise programs by adding resistance, guiding movement trajectories, or assisting in particularly difficult movements. Doing so creates a more involved experience for the patient that can help to improve adherence and make the exercises more enjoyable. Importantly, this technology provides even more data for the provider!
At UT Dallas, UT Southwestern and the VA North Texas Healthcare System we are observing the utility of virtual reality and haptics in a pilot study of our VIRTESH system (VIRtual-reality based TElerehabilitation System with Haptics) in a sample of patients with upper extremity impairment. In the study, participants enter a virtual environment with their provider from a remote location using Microsoft Kinect 2 RGB-D cameras, a rendering machine to render the environment in 3D and a 3D TV.
The virtual environment (Figure 1) places the provider and patient across from each other where they can physically interact via identical haptic devices (Figure 2) that, along with the cameras, are networked together over the internet. The telerehabilitation system combined with the haptic device’s six degrees of freedom and sensitive force feedback allows the provider to evaluate the patient’s isometric strength, range of motion over 10 movements (Figure 3), and pain from miles away.
These measurements are then compared to equivalent in-person assessments. The study results have been promising, with patients reporting a high degree of satisfaction with the virtual encounter when surveyed, and clinicians showing ~80% diagnostic agreement when in-person evaluations and remote evaluations were compared.
“Gamifying” Rehabilitation
Another important development in telerehabilitation is gamification of the technologies currently in use. Gamification is the use of principles of gaming in a non-gaming setting, and it can be used in physical rehabilitation applications to improve patient engagement. The important aspect is that new challenges of appropriate difficulty are introduced at the right time, progress is visualized, and that repetition is incentivized.
In a new study titled “Exergames,” we are seeking to take advantage of the benefits that a gamified telerehabilitation system may give to patients and providers. In the study, patients’ homes are set up with an Xbox Kinect camera and a laptop that includes a virtual reality game programmed with exercises prescribed by their physical therapist. In the game, patients will complete their exercise movements by popping bubbles that show up in sequence to guide them. They are accompanied by a recording of their physical therapist performing the same exercises to keep them on track. The program includes the required exercises at specified times with appropriate repetitions and sets, and records how the program has been used by the patient. This information, along with incidence of falls, is available to the provider for study. After a month the system will be removed from the patients’ homes and they will be evaluated for improvement, instructed to continue the program on their own while keeping a paper log, and then evaluated again two months later.
The possibilities for gamifying telerehabilitation systems go beyond what we aim to do with the Exergames study. Its ability to improve patient engagement can be amplified with other borrowed gaming concepts such as point systems, leaderboards, achievements, and daily/weekly challenge systems. As long as the rehabilitation goals are being met and the patient is enjoying therapy in a fun and safe way, progress is being made!
Conclusion
An original goal of telerehabilitation was to solve the problem that distance and travel barriers imposed on patients’ access to healthcare; communications technologies like the telephone and video calls sought to fit this need. Later, virtual reality and haptic technology greatly enhanced the quantity and quality of provider-patient interaction, and subsequently saw improvement in patient outcomes. Now with the trend towards gamification, telerehabilitation could be on the verge of drastically improving clinical outcomes by affecting patient motivation and satisfaction. While there is still much more work to do, there is promise of enjoyable, successful telerehabilitation therapies in the near future!
Cody Wolfe is a second year medical student at UT Southwestern. He is active in research involving virtual reality applications in healthcare and is pursuing a career in biomedical innovation alongside clinical practice.
