Mobile Game Based Applications for an Interactive Rehabilitation of an Upper Limb Paresis (draft) Jakub Mo˙zaryn, Adam Denys, Paweł Denys, Dariusz Szmechtig Warsaw University of Technology, Warsaw, Poland
[email protected]
Abstract A success rate of a rehabilitation process of an upper limbs paresis depends on a fast introduction of specialized physical excercises. One way to make them less burdensome, by increasing their attractiveness and availability, is to create solutions based on computer games. An article describes applications for mobile devices that can be used in the interactive rehabilitation of the upper limbs paresis. There are presented two types of applications, based on either internal sensors of a mobile device or the external active interface. Each of them is accompanied with the game for an improvement of user’s motivation. There are also presented frameworks for collecting and processing patient’s data, that can be used for supervision and contact with a clinician.
1
Introduction
As the result of a population ageing and social and lifestyle diseases, a growing number of people require rehabilitation of an upper limb paresis, that arises in a consequence of accidents, heart attacks, strokes or tumors [1], [2]. Particularly nowadays a stroke is emphasized because it affects growing number of people every year. Stroke survivors often suffer an upper limb paresis, and problems with coordination of hand movements. A stroke rehabilitation process should begin as soon as possible, ideally in special treatment centers, but in reality an admission takes several months. Furthermore, a treatment requires lengthy, tiresome and tedious sessions, that are highly demotivating factors for patients. Therefore there is a need for new techniques to make a rehabilitation common, 1
Mo˙zaryn, J. et al. beginning within a short time, and that may lead to a larger number of patients recovering to a partial or full movement capability. One proposed solution is to use modern multimedia techniques, such as VR (virtual reality) systems and computer games. Recently, fast-growing area of interest is designing of applications for mobile devices e.g. smartphones or tablets. Mostly because they are now becoming popular and more accessible to average-income users. Such solutions enable a self-training of patients under a supervision and a remote monitoring of a rehabilitation progress. A therapeutical effect can be reinforced by providing attractive exercises using interactive computer games. This paper presents prototype applications for mobile devices that can be used in the upper limbs paresis rehabilitation. There are discussed two solutions, with prototype examples, of devices for collecting patient’s data, where computer games are used. Next, there are given recommendations on their design. Then there are described different frameworks for data exchange and communication between a patient and a clinician. Finally concluding remarks are given.
1.1
Stroke
A Stroke is defined as a sudden death of nerve cells in a brain, caused by hypoxia, due to disturbances in a blood supply to the brain or a rupture of an artery. According to the World Health Organization (WHO), 15 million people suffer stroke worldwide each year. Of these, 5 million die and another 5 million are permanently disabled 1 . A risk of a stroke increases dramatically after an age of 55. Every year in Poland about 70 000 people experience a stroke, and the number of young people stricken by it is increasing [3]. Summarizing, in Poland: • 30 % of patients (21 000) die of a stroke, • 70 % of patients, who survived an acute period of a stroke, are disabled (usually later 1/3 of them die), • in 1/3 of patients, huge functional deficit remains, mainly in a form of a paralysis, an aphasia and disorders of a higher nervous activity, • in a remaining group (approx. 16 000) a functional impairment is lower, and they are partially capable to function independently. Within stroke survivors, there are different symptoms, that disrupt their normal condition [2]. They can suffer cognitive [4], visual [5] and motor losses [6]. Furthermore, because of a traumatic experience, patients usually experience a depression and an anxiety that negatively affects a treatment process [7]. 1 http://www.strokecenter.org/
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Mobile Game Based Applications for an Interactive Rehabilitation. . .
1.2
Rehabilitation of an upper limb paresis
A purpose of a limb rehabilitation is to prevent abnormal motor patterns, contractures and numbness. To overcome such symptoms there are used different physical and occupational therapies. In a stroke recovery a rehabilitation usually begins with a transition from a lying to sitting, and finally to a standing position. A therapy on the lower extremity is a primary concern in an early stage, in order to enable mobility of a patient. When a patient reaches satisfactory results in a coordination of the lower limbs, the rehabilitation of the upper limbs begins [2]. There are few important features and drawbacks of a traditional rehabilitation that should be considered [8]. The rehabilitation should start as soon as possible, but admission to a special center, where variety of exercise equipment is provided, often takes few months [9]. The limb therapy after a stroke requires a specific set of rehabilitation exercises and a long recovery time [10]. A standard set of exercises requires frequent, regular repetitions. Such exercises are tedious, causing a motivation decrease especially during a prolonged rehabilitation. On the other hand, a reduction of a rehabilitation period and therapeutic interventions can lead to permanent disabilities. Finally, a monitoring of a patient’s condition is limited. It requires frequent and long meetings with clinicians, what is generally difficult or even impossible [11]. Moreover, analysis of a patient’s state is complicated, as there exist numerous, special procedures to evaluate it 2 [2] e.g. Fugl-Meyer an assessment of a motor recovery after a stroke, the Brunnstrm test, MMT - a Manual Muscle Test. In our research we’ve decided to focus on the upper limb rehabilitation process. It’s less invasive and in some cases supervising clinicians propose everyday excercises that can be performed by a patient alone, to improve movement capability of a hand [2, 12]. We consider a set of excercises that is presented in Table 1.
2
Game-based rehabilitation therapies
Many research institutions, rehabilitation centers, hospitals and medical companies recognize an importance of an automated assistance in a rehabilitation process and emphasize a positive impact of specially designed computer games [13]. First therapies using a virtual reality (VRT - virtual reality therapy) were proposed in 1994 [14]. Within next years there were created different systems, mainly for military purposes, for a post traumatic disorder (PTSD) treatment [15]. Since a beginnig of the XXI century there had been porposed interactive computer based rehabilitation systems for civilians where gaming platforms were used. Their evo2 http://www.rehabmeasures.org/
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Mo˙zaryn, J. et al. Table 1. Set of excercises proposed for an upper limb rehabilitation No. E1.1 E1.3 E1.4 E1.5 E1.6 E1.7 E1.8 E1.9 E1.10 E1.11 E1.12 E1.13
Desctiption Clenching a fist. Dorsal and palmar bending of a wrist. Circulatory movements of a wrist. Pinning an object (e.g. ball) down and turning it on the ground. Bending a wrist back while a palm stays on a flat surface. Keeping a weight on fingertips. Folding and unfolding fingers. Pressing fingertips together Opposing a thumb. Sliding hand on an object. Grasping an object with fingertips. Shaping precise movements.
lution can be briefly described in the following, overlapping, phases: • Phase 1: Dedicated VRT systems with external interfaces (since 1999) MIT Manus[16], TheraJoy [17], Gentle/s[18], GestureTek [19], IREX [19]. • Phase 2: Game consoles (since 2004) - Sony Play Station [19, 20], XBOX [21]. • Phase 3: Game consoles with external interfaces (since 2008) - Wii [22, 23], Kinect [24], Sony’s Eye Toy [19], OculusRift [25], Intel RealSense[25]. • Phase 4: Platforms based on augumented reality (AR) (since 2010) [26, 27, 28]. • Phase 5: Mobile platforms (since 2014) [29, 30, 31, 32, 33]. It can be clearly visible from the list above, that a developement of game-based rehabilitation systems adjust immediately to new hardware and software solutions, especially ones that are mass-produced (game consoles, mobile devices). Such policy of institutions and researchers is understandable, because in case of a success there already exists a vast market for introducing interactive therapies. Automated platforms for practice at home or in rehabilitation centre supplement a classical therapy. Computer systems allow automated monitoring of an exercises performance and changes of a patient’s condition. Another virtue is a limitation of space and effort needed to prepare for exercises. A variety of activities carried out with the use of games, allows solving or performing tasks that require physical and cognitive activity at the same time. The 4
Mobile Game Based Applications for an Interactive Rehabilitation. . . engaging nature of games can increase the motivation to repeat exercises [34, 35]. Furthermore, it is easy to carry out many different excercises of varying complexity, with the adaptation to patient’s abilities. Researchers also emphasize an importance of a feedback on the learning rate improvement by inducing cortical and subcortical changes [36]. Such feature can be obtained by computer game, further contributing to keep the player engaged. To improve a motivation, rehabilitation games can be designed in a way that reinforce an interrelation of patients with their friends and family, to give them the sense of the social connectedness [37].
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Recommendations for a rehabilitation assistive game design
There is a growing interest in applications that use a video gaming and a social media for the rehabilitation, and there were performed numerous studies to examine clinicians perspectives regarding a technology adoption by patients. Tatla et al. [13] explored therapists perceptions of how young people and adults with a hemiplegia use gaming and social media technologies in the rehabilitation with upper limb training system. The purpose of the study was to identify barriers and facilitators towards these technologies. The study revealed that therapists were using technology in a limited capacity, mainly as one of many tools they could choose from. They identified barriers such as: a lack of an age appropriateness, privacy issues with a social media, a limited transfer of a training, and a lack of an accessibility of current systems. Therapists also questioned their role in the context of technology-based interventions. Obtained results in [13] can give an interesting insight into a design methodology of games used in the rehabilitation process. Mainly because there are many complexities associated with adopting new technologies in a clinical practice. First of all, a patient with special needs should be considered, as a person affected with a disease, usually traumatized. Therefore, there should be examined personal issues and differences in abilities of a healthy and an unhealthy person. Also, clinician factors should be treated, as a person that observes and supervises a patient, with the most decisive powers. Furthermore, there should be included an integration of games and a social media, to improve the efectiveness of such therapy. Based on [13], a set of recommendations for rehabilitation assistive games is gathered in Table 2. 5
Mo˙zaryn, J. et al. Table 2. The set of recommendations for rehabilitation assistive games [13] No. Desctiption Socio-emotional factors SE1: A possibility to interact and play with people who do not need a rehabilitation. SE2: A feedback and an encouragement to play. SE3: A simple adjustment of a game to user’s needs e.g. fonts, instructions. SE4: Taking into account different age, gender, interests of players. Rehabilitative factors R1: A possibility to strengthen a therapeutic objective. R2: An ability to assess movements. R3: An ability to use both hands. R4: Minimizing an impact of compensatory motions [38]. R5: A rational assessment of a progress e.g. reporting. Usability factors S1: An application should be simple to set up and learn. S2: A simple operation, attractiveness. S3: A sensory feedback (e.g. vibrations, sounds). S3: Using patterns known from common, popular games (e.g. a maze).
3.1
Mobile applications using internal sensors
Mobile devices are equipped with numerous sensors that read their state and working conditions, e.g. touch and multi-touch sensors, an accelerometer, a gyroscope, a magnetic field sensor, a light sensor, a proximity sensor, a temperature sensor, a barometer, a GPS (Global Positioning System) sensor. On a basis of sensory outputs it is possible to collect data about a performance of a manual action, which can be a subject of a further analysis and evaluation. In the Fig. 1 a process of using a mobile application for a rehabilitation purpose, based only on internal sensory outputs, is presented. When a patient performs excercises with a game, a device collects data from sensor measurements and process data in a form readable by a supervising clinician e.g. statistics, working conditions, a state of the patient. Moreover, a device connects with the user by sensory feedback (visual, auditory, tactile). The clinician, after an analysis of data can propose changes within a set of excercises and their intensity. It should be emphasized, that not all devices are equipped with all abovementioned sensors. A simple internet search revealed, that among 7 762 devices gathered by a popular comparison webpage 3 only 823 had gyroscope, and only 10 of them 3 http://www.gsmarena.com/
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Mobile Game Based Applications for an Interactive Rehabilitation. . .
Figure 1. A schematic diagram of an interactive system for a rehabilitation - using internal sensory data. had all sensors listed above. Therefore, during an application design, avilability of different measurement equipement should be considered. 3.1.1
Example: a maze game
In our research group, we had created a sample game, using recommendations given in Chapter 3, and utilizing only an accelerometer. The application is based on a popular maze game. The game objective is to bring a ball from a starting point to a finish line located in a lower right corner of a screen (see Fig. 2). It can be done by tilting device’s accelerometer. User’s task is to avoid obstacles: walls and holes on a virtual board. After a failed attempt, the game is resumed and a completed part (holes) of the maze is hidden. An aplication was written using Eclipse 4.5 4 enivironment, Java JDK (v. 8, update 77) 5 and XML 6 . Tests were performed using Samsung GT-S758034 smartphone with Android v. 4.2.2 7 operating system. The maze game fulfills in some extend given recommendations (see Table 3). However it is not an only issue that should be taken into a consideration. Very important is an ability to perform different excercises descibed in Table 1. The proposed game allow to perform the following excercises: E1.2, E1.3, E1.12. 4 https://eclipse.org/ 5 http://www.oracle.com/technetwork/java/index.html 6 https://www.w3.org/XML/ 7 https://www.android.com/
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Figure 2. A screen of the prototype maze game. Table 3. A fullfilment of recommendations (see Table 2) by the prototype maze game No. SE1 SE2 SE3 SE4 R1
Fulfilment no partial yes yes partial
R2 R3 R4 R5 S1 S2 S3 S4
yes yes partial yes yes yes yes yes
3.2
Comment a scoreboard, an auditory feedback an adjustment of a music volume and a speed of the game a popular type of a game a positive feedback from the patient, requires further clinical tests and evaluation data are collected for a further evaluation a user can tilt a device using both hands or one hand requires further clinical tests and evaluation a scoreboard, data are collected for further evaluation simple to learn, base on a popular type of a game a simple design with noninvasive colors and music an auditory feedback base on a popular type of a game
Mobile applications with an active external interface
An another idea of a mobile application requires a use of an active external interface. It can be simple, well known exercise device e.g. a soft ball, a sponge handle, rubber bands. Also, there are available interactive devices, created exclusively for automated rehabilitation systems e.g. musicgloveTM [39], Hand Mentor [40]. In the Fig. 3 there is presented a possible process of using a mobile application with an active external interface for a rehabilitation. When a patient performs excercises, data are collected from an active external interface equipped with sensors and then processed in the form useful for a supervision. Same data are also send to 8
Mobile Game Based Applications for an Interactive Rehabilitation. . . mobile devices that connects with user by sensory feedback. A clinician, after an analysis of data, can propose changes within a set of excercises and their intensity.
Figure 3. A schematic diagram of an interactive system for a rehabilitation - using an active external rehabilitation device.
3.2.1
Example: a soft-ball controlled Flappy Bird game
A proposed example, created in our reserch group, is a simple gaming system, that base on recommendations given in Table 2. As an active external interface there was chosen a rehabilitation soft-ball. Such balls, of various shapes and sizes, are popular excercise devices for a basic rehabilitation of upper limbs. Besides popularity, they have small size, low weight and are made of soft material - for that reasons they are not invasive and moderately safe for a user. Moreover, there is wide variety of possible excercises for different upper limb parts, that can be performed with a soft-ball (see Fig. 4). A picture of a created prototype is given in Fig. 5. In a rehabilitation soft-ball there was mounted Force Sensing Resistor (FSR-4068 ), created in PTF (Polymer Thick Film) technology. Its force sensitivity is optimized for use in a human touch control of electronic devices e.g. game controllers. It has a linear force curve, with a force sensitivity range between 0.1 - 100 N. When the ball was compressed a stress was transferred to a surface of the sensor. Moreover, in the ball was mounted Adafruit 8 http://www.interlinkelectronics.com/
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Mo˙zaryn, J. et al.
Figure 4. Sample excercises of an upper limb using a soft-ball: a) squeezing with fingertips, b) bending a forearm. FLORA LSM9DS09 sensor - a compact 3D digital accelerometer (linear acceleration full scale of ±2g/±4g/±6g/±8g/±16g ), 3D digital gyroscope (an angular rate of ±245/±500/±2000 dps) and 3D digital magnetometer (magnetic field full scale of ±2/±4/±8/±12). Therefore it allows to measure an acceleration, a spin and a twist of the ball. As a prototype controller there was chosen Arduino Uno Rev310 board. It collected data from all the sensors mounted within the ball. To communicate wirelessly with the mobile device, there was chosen HC-05 v2 11 module, which is a Bluetooth SPP (Serial Port Protocol) module, designed for a transparent wireless serial connection setup. To adjust voltage levels between the HC-05 module and the Arduino board there was used a bi-directional logic level converter - BOB-12009 ROHS12 . A communication between the mobile device and the Android board was established via a Bluetooth 2.0 + EDR (2nd class) protocol. A mobile device application was based on a popular game called Flappy Bird. It’s a side-scrolling mobile game featuring 2D graphics (Fig. 6-a). The objective is to direct a flying bird that moves continuously to the right, between sets of pipes. If the bird touches pipes, the player loses. Each pair of pipes, that the player navigates the bird between, earns a single point. In the designed prototype, bird briefly moves upward each time the user tightenes the soft-ball. Then, the mobile device collects data from the force sensor. An application was written using Android Studio (v. 1.3.2)13 and Java JDK (v. 8, update 77). Data for futher evaluation were collected with SQLite14 database. 9 https://www.adafruit.com/ 10 https://www.arduino.cc/ 11 https://www.itead.cc/ 12 https://www.sparkfun.com 13 https://developer.android.com/studio/index.html 14 https://www.sqlite.org/
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Mobile Game Based Applications for an Interactive Rehabilitation. . .
Figure 5. A prototype of an active external rehabilitation device: a) a breadboard with a Bluetooth module and a logic level converter, b) a rehabilitation soft-ball with sensors, c) a cable for sending data to controller, d) an Arduino controller with a power supply. Tests were performed with the smartphone Samsung Galaxy S5 with Android system 4.2.2. An application collects statistics from a session for both: a patient and a clinician. Data send to clinician (a number of presses, a playing time) are presented in the form of bar-graphs (Fig. 6-b). The proposed application with an active external interface and the Flappy Bird game fulfills in some extend recommendations given in Chapter 3 (see Table 4). It also allows to perform most of excercises listed in the Table 1.
3.3
Computer systems supporting supervision during rehabilitation
A proper rehabilitation requires a supervison and a continuous contact with a clinician (physiotherapist or doctor). This can be achieved using variety of platforms that can provide a communication and an analysis of the patient condition. 11
Mo˙zaryn, J. et al.
Figure 6. Screens from the mobile application with the soft-ball external interface: (a) the Flappy Bird game (b) game session statistics. Table 4. A fullfilment of recommendations (see Table 2) by the prototype Flappy Bird game No. SE1 SE2 SE3 SE4 R1 R2 R3 R4 R5 S1 S2 S3 S4
Fulfilment no partial yes yes partial yes yes unknown yes yes yes yes yes
Comment a scoreboard, an auditory feedback an adjustment of a music volume and a speed of a game a popular type of a game requires an analysis and clinical tests a scoreboard, data are collected for further evaluation a user can influence an external device using both hands requires an analysis and clinical tests a scoreboard, data are collected for a further evaluation simple to learn, base on a popular type of a game a simple design an auditory feedback base on a popular type of a game and its patterns
There exist different envirnonments and frameworks for a supervision of a rehabilitation process. They are usally designed as proprietary products or as tools for specific research project e.g. Teleposture [43], AR-REHAB [41], ubi-REHAB [32], CRehab [42], CRSS [30]. A drawback of such approach is a limited availability and as a result difficulty in wide implementation of already created solutions. In 2015, Apple Company launched ResearchKit15 , an open source software framework for a medical research, created for mobile devices with the iOS operating system. It enables investigators to create mobile applications that use the iPhones 15 https://www.researchkit.org
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Mobile Game Based Applications for an Interactive Rehabilitation. . . capacity to collect data, track a movement and take measurements with internal sensors of mobile devices. Main, customizable features, of this framework are: • An informed consent: modules for displaying and signing a consent form. The patient can clearly indicate when resigns from the supervison and use of the application. • Surveys: modules for a survey creation by inserting questions and types of answers. There are built-in encryption functions that allow to protect a medical confidentiality and personal data. • Active tasks: Modules that collect data from the mobile device sensors e.g. iPhone’s accelerometer, gyroscope, screen, microphone. ResearchKit allows to communicate between patient who is using iPhone and the person analyzing data e.g. clinician. Transmitted data may be a given excercise or a medical information e.g. a request to send the current level of pressure or the heart rate of the person under supervison. Moreover, it is possible to force an operation of some components of a device e.g. GPS, or data transmission over the cellular network. This supports monitoring of the patient and allows to quickly react to changes in the patient’s medical condition. Just after launching, the ResearchKit gained an attention of a research community. It was used in the clinical observational study about the Parkinson disease, conducted purely through the iPhone application interface (mPower) [44]. Another application, MoleMapper [45] was designed to advance a melanoma research. A drawback of the ResearchKit is a limitation to devices with the iOS operating system. According to the NetMarketShare16 (March 2016), which tracks network traffic, iOS (Apple products) had a global market share at the level of 31.76%. Based on the same results, Android operating system had a global market share of 60.99% (1.4 billion of devices). Therefore, to increase an application’s availability, especially for people with a lower income, such rehabilitation system should be also designed for Android devices. In 2015, Cornell Tech’s Small Data Lab17 and Open mHealth18 created the ResearchStack19 - a framework for devices with the Android operating system. It has a shared functionality and a common framework and naming scheme as the ResearchKit, therefore allows an research applications migration form iOS to Android [45]. 16 https://www.netmarketshare.com/ 17 http://smalldata.io/ 18 http://www.openmhealth.org/ 19 http://researchstack.org/
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4
Conclusions
The article presents different types of mobile applications for a rehabilitation of an upper limb paresis, that use computer games games. There are highlighted disadvantages of standard rehabilitation and essential elements of an automated computer system where games are used. There are proposed and presented prototypes of two applications - one using internal sensors of the mobile device, and another one using an active external interface. The preliminary analysis of presented solutions shows that they meet a majority of recommendations proposed on the basis of surveys conducted among clinicians and physiotherapists that were using similar applications. Proposed solutions met with the approval of doctors from Grochowski Hospital in Warsaw and Medical University of Warsaw and a further cooperation is planned. It should be noted that an application with an external interface allows to perform more of proposed rehabilitation exercises than application that uses only internal sensors of a mobile device. Therefore, a promising direction of the research can be a further development of the external interface based on the soft-ball. This can be done by a miniaturization of the prototype system by a placement of sensors, the controller and the Bluetooth module within the external device. However, the most important step will be a design of a computer system that will assist a clinician in performing tests and evaluations of the patient’s condition over time and facilitate adjustments in the therapy. This can be done through a utilization of open frameworks such as the researchKit and the researchStack for a patient’s continuous supervison and contact with a clinician.
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