Interactive supported ortho rehabilitation medstro proposal

© Insight 2014. All Rights Reserved
Interactive Supported
Orthopedic Rehabilitation….
4G-PT
19 February 2015
Prof Brian Caulfield

© Insight 2014. All Rights Reserved© Insight 2014. All Rights Reservedrates rising dramatically in recent years – doubled since 2000
Elective Orthopedic Surgery

© Insight 2014. All Rights Reserved© Insight 2014. All Rights Reserved
Recent Trends…..
•  Efficiencies in immediate post surgical care have resulted
in reduced post surgical inpatient care duration in recent
years
•  This greatly reduces the immediate cost burden.
•  However, it necessitates greater efficiency and quality of
care in post inpatient rehabilitation effort (and more
effective pre-surgical preparation)
•  Therefore, a significant portion of the rehabilitation effort
is taking place outside clinical environment
19/02/2015 Slide 3

Moving to Outpatient Rehabilitation Model
•  Reduced length of inpatient stay post surgery means we
need to fill the gap in other ways
•  Currently this is met with a combination of
•  Outpatient visits to physiotherapy / physical therapy
•  Participation in exercise classes on outpatient basis
•  Home visits from physiotherapist / physical therapist or nurse
•  Though less expensive than inpatient care, this still
constitutes a significant burden on the system
•  It is also leads to risk of reduced quality of care due to
diminished contact between patient and the system
19/02/2015 Slide 4

Driving Greater Efficiency
•  We can increase efficiency, and quality of care, if we ask
the patient to take on a greater role in and responsibility for
their rehabilitation effort
•  However, doing this requires that we provide the patient
with the knowledge and tools to empower their role
19/02/2015 Slide 5

© Insight 2014. All Rights Reserved© Insight 2014. All Rights Reserved 19/02/2015 Slide 6
patients often report that being
discharged home after joint
replacement surgery is like
‘falling off the edge of a cliff’
‘I received constant attention in the
hospital and then found myself at home
with nobody to turn to for help’
we need to support them

Barriers to Greater Patient Role in
Outpatient Rehabilitation
•  Progress in out-patient rehabilitation hampered by
critical challenges.
•  Lack of patient knowledge regarding issues such
as self care, correct use of walking aids, and
post-surgical precautions
•  Lack of patient confidence regarding progression
of rehabilitation and physical activity, and
weaning from walking aids
•  Poor adherence to targeted rehabilitation
exercise programme

Adherence to Exercise Programme
•  We know from previous research that 60-70% of
patients admit limited compliance with prescribed
rehabilitation exercise
•  Actual percentage likely to be worse!
•  Poor adherence related to 2 critical issues
•  Lack of motivation leading to poor compliance with
prescribed exercise between clinic visits
•  For those who are motivated to do the exercises, there is
evidence of inadequate adherence to correct exercise
technique due to inability to recall exercise specifics
19/02/2015 Slide 8

Empowering the Patient
•  Empowering the patient to take on a greater role in
and responsibility for their own rehabilitation could
deliver
•  Reduced need for outpatient clinic visits
•  Reduced need for home visits
•  Increased quality of care
•  Increased patient confidence, satisfaction and quality of life
•  Reduced likelihood of post surgical complications
19/02/2015 Slide 9

How is this achieved today?
•  Booklets & Web Resources…..
•  Exercise prescription aids
•  Interactive exercise feedback systems
19/02/2015 Slide 10
Total Knee Replacement Exercise Guide
This article is also available in Spanish: Ejercicio después de reemplazo de rodilla (topic.cfm?topic=A00494).
Regular exercise to restore your knee mobility and strength and a gradual return to everyday activities are
important for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that you
exercise approximately 20 to 30 minutes two or three times a day and walk 30 minutes, two or three times a day
during your early recovery.
Your orthopaedic surgeon may suggest some of the following exercises. The following guide can help you better
understand your exercise/activity program, supervised by your therapist and orthopaedic surgeon.
Early Postoperative Exercises
Start the following exercises as soon as you are able. You can begin these in the recovery room shortly after
surgery. You may feel uncomfortable at first, but these exercises will speed your recovery and actually diminish
your postoperative pain.
Quadriceps Sets
Tighten your thigh muscle. Try to straighten your knee. Hold for 5 to 10 seconds.
Repeat this exercise approximately 10 times during a two minute period, rest one minute and repeat.
Continue until your thigh feels fatigued.
Straight Leg Raises
Tighten the thigh muscle with your knee fully straightened on the bed, as
with the Quad set. Lift your leg several inches. Hold for five to 10
seconds. Slowly lower.
Repeat until your thigh feels fatigued.
You also can do leg raises while sitting. Fully tighten your thigh
muscle and hold your knee fully straightened with your leg
unsupported. Repeat as above. Continue these exercises
periodically until full strength returns to your thigh.

Exercise Prescription Aids
online video instruction
printed material
Our research has shown that video
instruction is less effective than
both memory recall and realtime
feedback based on inertial sensor
tracking of limb movement during
rehabilitation exercise
Doyle et al (2011)

of the research team using a random number generator. Clinical as-
sessment was conducted exclusively by a trained physiotherapist who
had no knowledge of the patient’s group assignment.
Statistical analysis
Categorical variables are given in absolute and percentage values.
Quantitative variables are given together with the mean and standard
2
or the fisher
Fig. 2. Patient using the interactive virtual telerehabilitation knee rehabil-
itation software.
Fig. 3.
Not randomized(n=324)
Reasons:
191 subjects refused
133 subjects excluded
Randomized (n=181)
Participants assessed for eligibility
(n=505)
Control group (n=91)
Withdrawals (n=21)
Local complication (n=3)
Active range of motion (n=18)
Intervention (IVT) group (n=90)
Withdrawals (n=18)
Local complication (n=2)
Active range of motion (n=16)
Completed the trial at baseline
(n=70)
Completed the trial at baseline
(n=72)
Completed the trial at 10 days
(n=70)
Completed the trial at 10 days
(n=72)
Lost to follow-up (n=5) Lost to follow-up (n=4)
Completed the trial at 3 months
(n=68)
Completed the trial at 3 months
(n=65)
J Rehabil Med 45
Interactive Exercise Feedback Systems
inertial sensor based
camera based
These have enormous potential.
However they require dedicated
hardware and don’t provide
detailed biomechanical feedback

•  These are all separate systems
•  Patients need a solution that addresses all their needs in
one system…..
•  We are proposing a trial that examines the value of
bringing all supports together in one wearable and mobile
solution……
19/02/2015 Slide 13

4 interrelated elements to an end-to-end solution
•  EDUCATION – Ensure that the patient has access to the relevant information that will
meet their information needs
•  INTERACTIVE EXERCISE – Provide the patient with the means to get real-time
feedback during targeted rehabilitation exercise sessions
•  MONITOR PROGRESS – Provide the patient with tools that allow them to objectively
monitor their progress and response to rehabilitation effort
•  COMMUNICATION – Enable a communication channel between patient and clinic
19/02/2015 Slide 14

Solution – 4G-PT
•  We propose a truly mobile and wearable solution, called
4G-PT
•  Low cost – leverages existing technology by using the
patient’s own smartphone to
•  Track limb movement during targeted rehabilitation exercises,
•  Quantify daily activity levels,
•  Serve as input device for patient reported outcomes
•  Serve as data aggregation, communication and feedback interface
•  Designed to meet patient needs and addresses 4 elements
outlined above
•  Deployed via a mobile app……
19/02/2015 Slide 15

EXERCISE PROGRESS MESSAGES
4G-PT
19/02/2015 Slide 16
INFORMATION

Deployment Options
•  4G-PT V1
•  Smart-phone as sensor and feedback interface
•  4G-PT V2
•  Smartphone as sensor & additional display device as feedback
interface (tablet, laptop, tv)
19/02/2015 Slide 17

4G-PT V2

Exercising?
Which
Exercise?
SLR
Hip Ext
Knee Ext
IRQ
Hip Abd
Knee Slide
Hip Flex
Correct or
Incorrect
Technique?
Yes
No
Which
Deviation?
Ext Rot’n
Hip
Hip Hitch
Heel Lift
Feedback
‘Your knee is
rolling
outwards.
Try to move it in
a straight line
as you bring it
towards you.’
uses machine learning based multi level and label classifiers for
accurate and objective rating of performance and delivery
of targeted feedback to patient during exercise

Proposed Clinical Trial
•  Prospective controlled trial
•  Leg 1 – Standard care
•  Leg 2 – Standard care plus 4G-PT V1
•  Leg 3 – Standard care plus 4G-PT V2
19/02/2015 Slide 21

Evaluation Criteria
•  Evaluate impact of 4G-PT implementation on
•  Patient satisfaction and QOL
•  Functional Performance
•  Utilization of services
•  Rate of complications
19/02/2015 Slide 22

Background Research
1.  Giggins OM, Sweeney KT, Caulfield B. Rehabilitation exercise assessment using inertial sensors: a cross-
sectional analytical study. J Neuroeng Rehabil. 2014 Nov 27;11(1):158. PMID: 25431092
2.  Giggins OM, Persson UM, Caulfield B. Biofeedback in rehabilitation. J Neuroeng Rehabil. 2013 Jun 18;10:60.
doi: 10.1186/1743-0003-10-60. PMID: 23777436
3.  Daniel Kelly, Barry Smyth, Brian Caulfield, “Uncovering Measurements of Social and Demographic Behaviour
from Smart-Phone Location Data”, in IEEE Transactions on Human Machine Systems 2013; 43 (2): 188-198
4.  Oonagh Giggins, Kevin T Sweeney, Brian Caulfield. The use of inertial sensors for the classification of
rehabilitation exercises. Proceedings of Engineering in Medicine and Biology Society (EMBC), 2014 36th
Annual International Conference of the IEEE. P 2965-2968
5.  Giggins O, Kelly D, Caulfield B.
Evaluating rehabilitation exercise performance using a single inertial measurement unit. Proceedings of the
7th International Conference on Pervasive Computing Technologies for Healthcare. ICST (Institute for
Computer Sciences, Social-Informatics and Telecommunications Engineering). 49-56
6.  Daniel Kelly, Brian Caulfield.
An investigation into non-invasive physical activity recognition using smartphones. Conf Proc IEEE Eng Med
Biol Soc. 2012 Aug;2012:3340-3. doi: 10.1109/EMBC.2012.6346680. PMID: 23366641
7.  Caulfield B, Blood J, Smyth B, Kelly D. Rehabilitation exercise feedback on Android platform. In
Irwin Mark Jacobs, Patrick Soon-Shiong, Eric Topol, Christofer Toumazou (Eds.): Proceedings of Wireless
Health 2011, WH 2011, San Diego/La Jolla, CA, USA, October 10-13, 2011. ACM 2011, ISBN 978-1-4503-0982-0
8.  Doyle J, Kelly D, Caulfield, B. Design considerations in therapeutic exergaming, 5th International Conference
on Pervasive Computing Technologies for Healthcare (Pervasive Health), pp.389-393, 23-26 May 2011
9.  Doyle J, Kelly D, Patterson M, Caulfield B. The effects of visual feedback in therapeutic exergaming on motor
task accuracy. 2011 International Conference on Virtual Rehabilitation (ICVR), pp.1-5, 27-29 June 2011 doi:
10.1109/ICVR.2011.5971821
10.  O'Huiginn, B.; Coughlan, G.; Fitzgerald, D.; Caulfield, B.; Smyth, B. Therapeutic Exergaming, Proceedings of
Body Sensor Networks 2009, Berkeley, California, June 4-6 2009
19/02/2015 Slide 23

For more information
•  b.caulfield@ucd.ie
•  +353833487198
•  @caulfieldbrian
•  www.connectedhealthireland.com
19/02/2015 Slide 24

Interactive supported ortho rehabilitation medstro proposal

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