University of Gothenburg 1 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21,

University of Gothenburg 2 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Stroke Rehabilitation at Home: A Case Study of the Latest eHealth Achievements Prize Winner of Best IT-Project in Discipline Health Care (Sweden) Martin Rydmark, MD, Ph.D., Associate Professor, Mednet, Inst. Biomedicine, The Sahlgrenska Academy, University of Gothenburg, Göteborg (Sweden) Team: Christian Blomstrand, MD, Ph.D., Professor Jurgen Broeren, Ph.D., OT Daniel Goude, B.Med, M.Sc. Hans Samuelsson, Ph.D. Katharina S Sunnerhagen, MD, Ph.D., Professor Associates: Ulrika Dreifaldt, Research student Karljohan Lundin Palmerius, Ph.D. Emelie Sabe, M.Sc. With permission of:

University of Gothenburg 3 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, 2008 Current Traditional Stroke Rehabilitation

University of Gothenburg 4 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Rationale Stroke is common, ~ 30,000/y in Sweden and >1M/y in USA Motor/sensory, cognitive and other impairments are clinically assessed Rehabilitation is mostly necessary and of long duration, months -> years Clinical rehabilitation works well Training should be daily and at max capacity, cf. coaching in sports Home based or out-patient rehabilitation works less successful Compliance to training is low (“two weeks rule”) and assessment is nil or poor. Most often training is non-existing Travelling to and from clinics is tiring and expensive VR – 3D & Haptic Assessment and Training with Telemedicine Communication at HOME might be engaging/fun and effective for Rehabilitation? Individualized training with “serious-games” and engaging activities should be employed The system must be simple to handle and inexpensive Systems should be net-working and have video/audio communication © MR

University of Gothenburg 5 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Proposed Regional Rehabilitation Organization Friends & Relatives

University of Gothenburg 6 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, We have published results of >100 people assessed and trained in lab and clinical settings and at day care centers, see Main categories: healthy references 75% stroke patients with motor impairments 15% stroke patients w. neglect/recovered neglect 10% builds and distributes Home Rehabilitation Systems and Clinical Assessment Systems,

University of Gothenburg 7 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Kinematic Assessment: Hz

University of Gothenburg 8 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Slingball Haptic Simon Early games and engaging activities ConductingGardening (tentative)Sculpturing(tentative)

University of Gothenburg 9 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Assessment session Velocity (m/s) ,00 0,05 0,10 0,15 0,20 0,25 P2 P3 P4 P5 P1 Baseline (A)Intervention (B)Follow-up (C) RESULTS: Assessment and training of motor function

University of Gothenburg 10 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Before After Follow up 5w 12w Training effect on movement pattern, velocity and acceleration Start point End point

University of Gothenburg 11 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Reference no: 8 RESULTS: Neglect assessment

University of Gothenburg 12 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Patient no:4 Neglect assessment

University of Gothenburg 13 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Search pattern Reference Clinically Recovered Neglect??? – Subject 1 Neglect – Subject 3 ‘Cobweb’-like hesitations? Neglect assessment

University of Gothenburg 14 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Evaluation and speculations Patients enjoy working with the VR/haptic equipment Subjectively the patients express improvements in motor function and some even in sensory and cognitive functions Assessment works at least as well as with traditional test tasks Assessment is quantitative, automatic and present kinematic information Cost efficiency is good

University of Gothenburg 15 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Ongoing R&D 1)Development of a taxonomy bilaterally connecting medical terminology with game design patterns. 2) Creation of individualized training schedules based on clinical analyses. 3)Refine existing serious games, develop new activities, and analyze COTS games (in cooperation with Chalmers University). 4)Further development of patient and therapist interface for bio-feedback. 5)Create a (semi) automatic adaptive algorithm for individualized adjustment of level of serious game difficulty and movement control. 6)Realize real-time Internet interaction within the rehabilitation system, using combined 3D/stereo-visualization, haptic/robotic interaction, and social voice/video communication (proposed cooperation with SICS, Sweden, and C-DAC, India). 7)Explore the use of alternative "haptic-robotic" technology at an affordable price and sufficient quality and motor force (in cooperation with Linköping [Norrköping] University). 8) Expanding the scope of conditions to NeuroRehabilitation, incl. CP, TBI, etc. 9)Correlate Kinematic outcome of Rehabilitation with fMRI (discussions with colleagues at Stanford University).

University of Gothenburg 16 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, 2008 Kinematic Assessment – ”Point Test” Graphic feedback of Kinematic Movement Pattern

University of Gothenburg 17 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Taxonomy Relating Medical Terminology and Game Design Taxonomy created to bridge medical terminology and game design Design of new activities and evaluation of COTS (Commercial Off The Shelf) games Cognitive impairments Taxonomy Game Design PatternsGames

University of Gothenburg 18 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, Game Selection Menu Extra: Screen shots of the patient and the therapist interface available on demand. Contact me after this session. Haptic 3D stylus

University of Gothenburg 19 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, 2008 Technical Challenges: Network Intra data prioritisation –Haptics, Audio/Video, 3D, Assessments Inter data prioritisation –Coordinating multiple sessions Preventative actions during congestion –Graceful degradation, no unexpected surprises for patient –Local logging Later replay of movements –Single-user mode Future session bandwidth scheduling

University of Gothenburg 20 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, 2008 Technical Challenges: Volume Haptics & Robotics Proxy Force

University of Gothenburg 21 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, 2008 Medical Challenges Unbroken rehabilitation chain Distributed neurorehabilitation use cases –Outpatient –Home –Community center –Assisted living Stroke, CP, TBI, PTSD, Parkinson’s, Alzheimer’s, etc.

University of Gothenburg 22 Sweden – Cutting Edge in Health Care - House of Sweden - Feb 21, URL: Thank you for your attention! This presentation is found under Documents & Files at the URL, below!