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 Reserved

rates rising dramatically in recent years – doubled since 2000

Elective Orthopedic Surgery


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 GuideThis 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 areimportant for your full recovery. Your orthopaedic surgeon and physical therapist may recommend that youexercise approximately 20 to 30 minutes two or three times a day and walk 30 minutes, two or three times a dayduring your early recovery.

Your orthopaedic surgeon may suggest some of the following exercises. The following guide can help you betterunderstand 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 aftersurgery. You may feel uncomfortable at first, but these exercises will speed your recovery and actually diminishyour postoperative pain.

Quadriceps SetsTighten 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, aswith the Quad set. Lift your leg several inches. Hold for five to 10seconds. Slowly lower.

Repeat until your thigh feels fatigued.

You also can do leg raises while sitting. Fully tighten your thighmuscle and hold your knee fully straightened with your legunsupported. Repeat as above. Continue these exercisesperiodically until full strength returns to your thigh.

Ankle Pumps

Move your foot up and down rhythmically by contracting the calf and shin muscles.Perform this exercise periodically for two to three minutes, two or three times an hour inthe recovery room.

Continue this exercise until you are fully recovered and all ankle and lower-leg swelling has subsided.

Knee Straightening Exercises


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)


394 M. Piqueras et al.

(mean length of stay 6.2 days) and outpatient intervention (outpatient SK\VLFDO�WKHUDS\�RU�,97��IRU�WKH�¿UVW��ZHHNV�DIWHU�VXUJHU\��,QSDWLHQW�care consisted of assisted walking within 24 h, knee range of motion exercises and preparing for the return home.

After hospital discharge, conventional physical therapy consisted of a 2-week face-to-face rehabilitation programme (progressive exercise and instruction including knee range of motion, gait training, and instructions in negotiating stairs and community-related obstacles). $Q\�VLJQV�RI�DGYHUVH�NQHH�MRLQW�UHVSRQVHV��H�J��LQFUHDVHG�VZHOOLQJ�RU�pain) resulted in a lowering of the intensity, frequency and duration of the exercises or elimination of a rehabilitation component.8QGHU� WKH� VWXG\� SURWRFRO�� DOO� SDUWLFLSDQWV� SHUIRUPHG� WKH� ¿UVW� ��

sessions under therapist supervision in the Knee function Unit of the Physical Medicine and Rehabilitation Department to ensure proper monitoring and avoid unnecessary risks related to surgical incisions and stitches. Before starting home-based intervention, patients were examined by a doctor to ensure the absence of complications that might result in exclusion from the study.

Daily 1-h sessions were scheduled (Monday to friday). The IVT group followed the pattern of exercises using the virtual platform under the therapist’s supervision (fig. 2). At the end of each session, data were sent to the therapist’s portal. Both groups were also given instruc-tions to continue the exercise routine over the weekend. Beginning on the sixth day, the IVT group continued the exercise programme at home. There were no complaints about setting up the system at home RU�PDMRU�SUREOHPV�DULVLQJ�IURP�XVH�RI�WKH�SRUWDO��ZKLFK�SDWLHQWV�IRXQG�to be very intuitive and easy to understand.

Except for the WOMAC instrument, administered preoperatively and at 3 months after TKA, all assessments were performed routinely WKH�¿UVW�GD\�RI�RXWSDWLHQW�UHKDELOLWDWLRQ��GD\V��6'��DIWHU�7.$��at the end of the rehabilitation programme (2 weeks), and at 3 months follow-up.

Randomization and blindingTreatment blinding and randomization were carried out by a member 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 analysisCategorical variables are given in absolute and percentage values. Quantitative variables are given together with the mean and standard GHYLDWLRQ� �6'��8QLYDULDWH� DQDO\VLV� XVHG� HLWKHU� WKH� Ȥ2 or the fisher

exact test for categorical variables and Mann-Whitney U test for TXDQWLWDWLYH�YDULDEOHV��7KH�OHYHO�RI�VWDWLVWLFDO�VLJQL¿FDQFH�ZDV��for all hypothesis testing.

Source of funding7KLV� VWXG\�ZDV� SDUWLDOO\� ¿QDQFHG� E\�7HOHIyQLFD�5HVHDUFK� DQG�'H-velopment.

REsUlTs

The trial procedure (fig. 3) followed the CONsORT recom-PHQGDWLRQV� �� )URP�1RYHPEHU� �� WR� 'HFHPEHU�2010, 505 patients underwent TKA, of whom 191 refused to participate in the study and 133 met at least one of the exclusion criteria (cognitive impairment, transfer to a geriatric centre). The remaining 181 participants were randomized at the time rehabilitation therapy was started.'XULQJ�WKH�¿UVW��VHVVLRQV��WKHUH�ZHUH��GURS�RXWV�EHFDXVH�

RI� MRLQW� VWLIIQHVV� �DFWLYH� NQHH�ÀH[LRQ�� DQG�RU� VXUJLFDO�wound complications (extensive skin necrosis, wound infec-tion): 21 patients in the control group and 18 patients in the IVT. Of the 142 patients who completed the intervention, ��ZHUH� ORVW� WR� IROORZ�XS� IRU�QR� MXVWL¿DEOH�PHGLFDO� FDXVH��belonged to the control group and 5 to the IVT.7KH�SDUWLFLSDQWV��PHQ�DQG��ZRPHQ��

KDG�D�PHDQ�DJH�RI��6'��\HDUV��7KH�SHUFHQWDJH�RI�PHQ�ZDV��LQ�WKH�FRQWURO�JURXS�DQG��LQ�WKH�,97��p ��

Fig. 2. Patient using the interactive virtual telerehabilitation knee rehabil-itation software.

Fig. 3.� 7ULDO� SUR¿OH� �&RQVROLGDWHG� 6WDQGDUGV� RI� 5HSRUWLQJ� 7ULDOV��&216257��ÀRZ�GLDJUDP��

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

•  [email protected]

•  +353833487198

•  @caulfieldbrian

•  www.connectedhealthireland.com

19/02/2015 Slide 24

interactive supported ortho rehabilitation medstro proposal

Healthcare

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progression of rehabilitation

greater patient role

prof brian caulfield

immediate post surgical