1. REMOTE REHABILITATION OF THE AGING POPULATION Challenges and appropriate technologies By Sreeram Dhurjaty, PhD, Rochester, NY, USA Dhurjaty Electronics Consulting LLC, Visiting Senior Research Faculty, Dept. of Physics and Astronomy, University of Rochester March 18, 2010 1 Indo-French Workshop on ICT for Health and Autonomy in Aging population, IIT, Jodhpur (Rajasthan)

2. Outline of Presentation Need for “remote rehabilitation”, physical and cognitive Early and current US experience in Telerehabilitation and related issues Shifting paradigms and opportunities Appropriate smart and affordable technologies Standards in metrics and communication Challenges in the Indian environment Enabling technologies and projects March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, IIT Jodhpur (Rajasthan) 2

3. Need for remote rehabilitation Adage: “a patient who is watched is compliant” Safety is enhanced by being watched/monitored Metrics pertaining to rehabilitation help both the patient and therapist gauge progress and increase the speed of rehabilitation by about 30% Challenges with “in-clinic” rehabilitation Regular travel to the clinic may be difficult, inconvenient and infeasible Availability of therapist for individual consultation, training Variability in equipment, therapists and metrics Aging population is beset with physical and cognitive impairments and need localized care March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 3

4. US experience in Telerehabilitation: Early experience Earliest rehabilitation was an extension of Telemedicine Therapist watched patient exercising on video Low bandwidth of POTs was unsatisfying Difficult to discern visual and other cues in standard video conferencing Jaron Lanier: http://www.jaronlanier.com/cocodexintro/cocoindex.html Intrusive and impersonal March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 4

5. Progress in telerehabilitation (some examples) Burdea, G, Rutgers Haptic s with visual feedback for upper and lower extremities and manipulation of video games to engage patient http://www.legacy.usabilitynj.org/files/WUD-NJ_2007-Deutsch-Keynote.pdf Greenleaf, Dhurjaty et al Pilot study in Houston and Stanford to gauge the efficacy of Physical rehabilitation of Hand injuries (50 patients) Used an instrumented glove with the range of motions manipulating a pattern on the screen Used metrics to gauge efficacy of telerehabilitation Various other investigators have used haptic feedback from video game controllers to facilitate telerehabilitation March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 5

6. Early challenges of implementing telerehabilitation in the USA Scant reimbursements from Insurance companies Rehabilitation of extremities has a lower reimbursement rate than stroke rehabilitation Lack of “buy-in” from major health care providers Cost of training, adoption of new protocols and difficulty in using equipment High capital costs of equipment and their deployment Unable to justify deployment costs in the home and liability Economical only in an industrial setting The Economics of Telerehabilitation, Sreeram Dhurjaty, Telemedicine Journal and e-Health. Summer 2004, 10(2): 196-199. Lack of standards and meaningful metrics for measurement, communication and storage March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 6

7. Shifting paradigms and opportunities Low-cost equipment The, ubiquitous, modern mobile phone is a powerful computational, display, communication and storage engine More processing power, storage, and faster communication than all of NASA in 1969 Early CT scanners (circa 1979) used 30 MHz bit-slice processors for computation Computational power rivals early supercomputers Some of the phones use accelerometers that can be used in sensing and other sensors can communicate via bluetooth March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 7

8. Shifting paradigms and opportunities (contd.) Training and adoption of new protocols Use existing low-tech devices and make them ‘smart” by adding low cost sensors; bootstrap on existing protocols Define and standardize the rehabilitation space Physical and cognitive(greater challenge) Define standards for sensing and measurement Standards for communication and storage Bootstrap on existing standards for communication and storage in hospitals March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 8

9. Making existing physical rehabilitation devices “smart” March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 9

10. Appropriate smart and affordable technologies Computation platforms Mobile Phone/Video game systems (WII) Devices Common “Low-tech” rehabilitation tools Sensors (physical) Accelerometers, video camera in phone Sensors (stress) GSR, Pulse oximetry, etc Usability Convenient, unobtrusive Rehabilitation as a game Training Stored as video/audio clips on phone March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 10

11. Standards in metrics and communication (an example) March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 11

12. Challenges in the Indian Environment Diffusion of technology to rural population Mitigate by education and training by trusted sources Multiple languages and scripts Mitigate by different packages for languages and scripts Unreliable power Mitigate by designing systems with commonly available batteries. This also enhances electrical safety Robustness Design systems to be rugged and appropriate for the operational environment March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 12

13. System flow diagram for remote rehabilitation March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 13

14. Enabling Technologies and Projects Rehabilitation devices Identify existing “low-tech” devices for various body parts Understand clinical use of devices and their efficacy Design new devices if necessary, appropriate to the Indian environment Quantify range of motion (ROM) parameters appropriate to each device Establish standards March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 14

15. Projects (contd.) Sensors Define accuracies and resolutions of sensors for rehabilitation devices Match existing sensors (e.g. Accelerometers, MEMS gyros, video camera) to rehabilitation devices Define electrical and communication interfaces and establish standards March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 15

16. Projects (contd.) Usability Operator interfaces audio and visual that relate to ROM Engaging activity that interfaces to rehabilitation parameters and provide timely feedback about progress Storage and communication of data to and from therapist Ability to modify rehabilitation protocols Enhance safety by preventing over exercising and monitoring of physiological parameters March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 16

17. Projects System Integration Sensors with devices Devices with mobile phone Mobile phone with therapist and central platforms Integrate data by bootstrapping on existing communication, storage and patient information systems March 18, 2010 Workshop on ICT for Health and Autonomy in Aging Population, 17