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Hindawi Publishing Corporation e Scientific World JournalVolume 2014, Article ID 495391, 11 pageshttp://dx.doi.org/10.1155/2014/495391Research ArticleeFisioTrack: A Telerehabilitation Environment Based onMotion Recognition Using AccelerometryDaniel Ruiz-Fernandez,1 Oscar Marín-Alonso,1Antonio Soriano-Paya,1 and Joaquin D. García-Pérez21Department of Computer Technology, University of Alicante, Carretera San Vicente del Raspeig s/n, San Vicente del Raspeig,03690 Alicante, Spain2Bio-inspired Engineering and Health Computing R.G. (IBIS), University of Alicante, Carretera San Vicente del Raspeig s/n,San Vicente del Raspeig, 03690 Alicante, SpainCorrespondence should be addressed to Daniel Ruiz-Fernandez; druiz@dtic.ua.esReceived 3 September 2013; Accepted 13 November 2013; Published 12 January 2014Academic Editors: Y. Cai and S. MaCopyright 2014 Daniel Ruiz-Fernandez et al. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.The growing demand for physical rehabilitation processes can result in the rising of costs and waiting lists, becoming a threat tohealthcare services’ sustainability. Telerehabilitation solutions can help in this issue by discharging patients from points of carewhile improving their adherence to treatment. Sensing devices are used to collect data so that the physiotherapists can monitor andevaluate the patients’ activity in the scheduled sessions. This paper presents a software platform that aims to meet the needs of therehabilitation experts and the patients along a physical rehabilitation plan, allowing its use in outpatient scenarios. It is meant tobe low-cost and easy-to-use, improving patients and experts experience. We show the satisfactory results already obtained from itsuse, in terms of the accuracy evaluating the exercises, and the degree of users’ acceptance. We conclude that this platform is suitableand technically feasible to carry out rehabilitation plans outside the point of care.1. IntroductionNowadays there is an ever-growing demand for rehabilitationprocesses within public and private healthcare services. In2011 the World Health Organization estimated that onebillion people worldwide were in need of rehabilitationtreatments [1]. What is more, this increasing demand isexpected to continue in time as the population that agedover 60 will grow (Figure 1). This is a worldwide matter thatin developed countries reaches its maximum due to betterwelfare and health conditions.Aging is recognised as one of the main causes of the needfor any kind of rehabilitation treatment, and its importancelies in the fact that it is unavoidable. Focusing on physicalrehabilitation, besides ageing, there are other prominentcauses for these therapies: musculoskeletal injuries, illnessesthat affect the locomotor system, and postsurgery scenarios.All these situations cause the loss of physical abilities, havinga clear impact on patients’ quality of life.Physical rehabilitation plans involve a set of differenttherapies that aim to return patients to a healthy conditionallowing them to recover a normal way of living. Theobjectives and the design of these plans vary depending ontemporary aspects of the disabilities. In case of permanentdisabilities, rehabilitation will probably last until the end ofthe patient’s life, having as unique goal the maintenance of hisself-sufficiency, or just decelerate the loss of physical abilities.If the disabilities are temporary, the objective of rehabilitationtherapies is to help patients to regain as much self-sufficiencyand lost skills as possible, in the minimum time, in order tolive a normal life.As it is easy to deduce, physical rehabilitation processesare highly cost-consuming, becoming a threat to the sustainability of healthcare services. Rehabilitation plans arerequired to be as efficient as possible to make them affordableto funding institutions. In these plans, efficiency depends onits logistics, organizational factors, and healthcare policies. Inaddition to this, patients’ attitudes and behaviour have a great
2The Scientific World Journal(%) Population aged 60 rth OceaniaAmerica Americaand theCaribbean20112050Figure 1: Population aging prospects of the United Nations’ Department of Economic and Social Affairs. Available online: http://esa.un.org/unpd/wpp/index.htm (last accessed on 10 March 2013).impact on this issue due to the concept of patients’ treatmentadherence. Treatment adherence is related to the degree inwhich patients follow the experts’ guidance and fulfill thescheduled clinical activities prescribed to them [2]. The lackof adherence within physical rehabilitation programmes hasbeen identified as one of the most important reasons fortreatment failure in pathologies of the locomotor system[3, 4]. There are studies showing that situations of pooradherence to treatment can result in longer recovery periods,growing waiting lists, or even new injuries caused by a wrongperformance of the prescribed exercises [5, 6]. We can statethat the lack of adherence physical rehabilitation treatmentsdirectly affects to the quality of rehabilitation services and thepatients’ quality of life.Patient’s attitude towards rehabilitation treatments can beinfluenced by several factors, which are related to him, hisrelation with the rehabilitation experts, and organizationalissues of the rehabilitation services. An example of this isthe importance of the scenarios in which the rehabilitationprocesses take place. We can distinguish between two mainsituations:(i) inpatient scenario, in which the patient goes to apoint of care in scheduled sessions and performs theexercises partially supervised by experts, since eachphysiotherapist attends many patients at a time. In(Figure 2) we can see flow diagrams of two common rehabilitation activities: first examination toevaluate patient’s condition and later supervision ofthe improvements made by the patient through arehabilitation plan;(ii) outpatient scenario, in this case after the prescriptionof a rehabilitation plan, the patient performs, usuallyat home, the exercises under no supervision. Expertscheck his evolution through regular meetings at thepoint of care.Inpatient scenarios require higher personnel cost butallow a more regular communication between patients andphysiotherapists. On the contrary, in outpatient situationsthis communication is almost nonexistent. So it is highlylikely that the patient does not remember clearly the expert’sinstructions to perform the exercises in his day-to-day rehabilitation sessions. Even more, as they perform them withoutsupervision, they will not receive any feedback about thecorrectness of their performance, until the next scheduledvisit to the physiotherapist office.In their study, Jack et al. observe the difference betweenadherence to treatment of patients involved in inpatient andoutpatient scenarios, respectively [7]. Patients’ motivationand adherence to treatment tend to decrease as they gothrough the rehabilitation plan in outpatient scenarios. Thestudy from Sniehotta et al. shows that motivation andinvolvement of patients are reinforced by an effective communication with the clinical experts, making the odds of patientadherence 2.16 higher [8]. Situations of low motivation andlack of involvement can result in low self-efficacy situations.All of them are important barriers to treatment’s adherence[9].Within the field of information and communicationtechnologies (ICT) we can find suitable solutions to face thepreviously described issues related to physical rehabilitationprocesses. After meeting with physiotherapists and reviewingrelated works, we decided to design a system to allow patientsto perform rehabilitation exercises in outpatient scenariosbut assuring the real-time communication between themand the experts at the point of care. In short, we aim toreduce the workload of healthcare services, making themmore efficient, while eliminating the gap between patientsand experts improving their experiences by using a low-costand easy-to-handle platform.To achieve those goals our system should monitor thepatients’ performance of the prescribed exercises, evaluateits correctness, and securely store these data. Furthermore,patients and physiotherapists should have access at any time(24 7 365) to all the data related to the rehabilitationplan, to obtain useful feedback. In this work we describedthe objectives of our project, its final design, and the test andvalidation processes carried out to show its feasibility to beused for telerehabilitation purposes.This paper is organized as follows. In Section 2, we showprevious approaches from other researchers to the issueswe face. In Section 3 we show our platform’s specificationdescribing the software and hardware components and theoffered services to physiotherapists and patients. Next, inSection 4 we show the platform in use, describing the evaluation procedures that have been carried out to test its validity.Finally, in Section 5 we show conclusions obtained afterthe design, implementation, and validation stages, includingfuture works to be developed from now on.2. Related WorksThe objective of improving the quality of health care and thefunctioning of healthcare services has led to many cases ofuse of ICT in the medical field. Our work is connected withthe concept of telemedicine, which aims to offer ubiquitous
The Scientific World Journal3Patients supervisionPatients examinationImprovements evaluationInjuries diagnosedNoQuestions to patientYesYesPhysical evaluation1st visit?Create historic recordNeed for longerrehabilitation?YesNoCreate a rehabilitation planNewrehabilitationneeds?Preliminary assessmentsBandages, manual therapies, and physicalmediumsNoNoYesUpdate rehabilitation planSchedule sessions of rehabilitation exercisesYesNew injuries?More injuries to treatYesNoNoCreate arehabilitation planEnd(a)End(b)Figure 2: Flow diagram of rehabilitation attention processes. On the left, patient’s 1st examination and on the right, patient’s improvementssupervision.healthcare services to patients. Within this concept, we cantalk about telerehabilitation as process in which a patientperforms tasks related to follow a rehabilitation plan, of anykind, outside a healthcare centre.Telerehabilitation proposals vary in their design sincethey are focused on different aspects of the rehabilitationprocess. These variations depend on the targeted user (patientor physiotherapist), their purpose (to test the use of new technologies, to improve the attention in outpatient situations,and so on), the disability and part of the body to be treated,and the environment in which the solution will be used.There is a prominent trend of works that use virtual realityand robotics to offer to patients innovative ways to performprescribed exercises. Some sensing devices are used to offerthe virtual reality feeling and to record useful data aboutpatient’s state and behaviour [10, 11]. These proposals are oftenshowed as games where the patients are required to makecertain gestures to interact with the game device. Virtualreality-based projects are mainly focused on rehabilitation inpoststroke or cerebral damage situations [12–14], while thosethat use robotics are aimed to rehabilitation of musuloskeletaldisabilities [15, 16]. Nonetheless, these works seemed tobe focused on testing the feasibility of these new ways ofrehabilitation, and they do not pay much attention to user’sfeedback, the communication between patients and experts,and how to evaluate the progresses made by the patients.In a ubiquitous scenario patients should be monitoredas they perform the rehabilitation exercises. Afterwards, theobtained data should be at physiotherapist disposal to be evaluated or examined. Motion tracking techniques are useful todo this task. A work by Zhou and Hu shows examples of theuse of multiple tracking systems for rehabilitation purposes,depending on the sensing devices and information processingalgorithms used [17].Inertial sensors have been extensively used for humanmotion tracking and recognition because of their low cost,simplicity, and availability. These sensors have been applied torecognize and measure human activities [18, 19] and to trackand evaluate certain gestures performance [20]. Both tasksare useful in telerehabilitation scenarios.Inertial sensors are often combined with other sensors,inertial or not. This is done to avoid some disadvantagesof these sensors like drift when estimating 3D coordinatesor noise in the gathered data, due to sensor rotations,displacements, or other perturbations [21–23]. The fusion ofsensors helps to achieve more robust and accurate trackingsystems. On the other hand, these systems have to deal withcomplex tasks like the fusion and processing of motion data.Furthermore, they are also intrusive and uncomfortable towear due to the need of placing several sensors on the user’sbody.Taking into account the need of a low-cost system andthe patient’s autonomy and comfort, we tested the possibilityof using one single inertial sensor. We choose a gamepadmanufactured by Nintendo, the Wii Remote , that includesa three-axis accelerometer [24]. Wii Remote has been usedfor general-purpose gesture recognition [25, 26] and in fewrehabilitation projects as well [27–29]. In these projects it isused as tool to collect motion data, but it is not integrated ina wider system to support rehabilitation processes’ needs.
4After reviewing previous works we had insight of severalissues that should be considered to design a low-cost, easyto-use, and able-to-generalize rehabilitation system. Manyof them are focused only on rehabilitating concrete parts ofthe body [30, 31], or the consequences of certain conditionslike stroke. Due to its complexity and the use of multipledevices, their design is sometimes intrusive making some ofthem hardly suitable for domiciliary scenarios and affectingpatients’ motivation. In addition, this complexity may affectto cost, making them not affordable for healthcare services.Finally, it has been proved that issues related to users shouldbe taken into account [32] when designing a telerehabilitation solution, moreover, if they will use the system underno supervision, as it is the case of patients in outpatientscenarios.The Scientific World Journal3.1.2. Objectives Related to Rehabilitation Services’ Functioning. All the services that the system will offer must be integrated within the current rehabilitation services workflow.This means that eFisioTrack will not be a standalone application just to monitor outpatient performance of exercises.Besides, in the same environment the expert will be ableto carry out all the tasks that involve dealing with patients:administrative work, agenda planning, access to patients’history, examination and prescription of complementarytherapies, and so forth.eFisioTrack is not focused on a certain joint or a part ofthe body. It will be able to cope with the rehabilitation ofdifferent disabilities and injuries, offering an upgradable setof exercises to do so.3.1. Objectives of eFisioTrack. Primary objective of efficiencycan be fulfilled through achieving other secondary ones,which can be grouped paying attention to the aspects ofthe rehabilitation processes they affect: technology, users(patients and physiotherapists), and rehabilitation services’functioning.3.1.3. Objectives Related to Technology. The interaction mechanisms between patients and experts should be presented ina friendly environment, through comprehensive interfaceswhere the different options are logically disposed followingcommon rehabilitation workflow. This is important to avoidrejection due to complexity of usage.Achieving a low-cost system is a challenge that is takeninto account at the time of the system’s architecture design.This challenge is behind the election of a sensing deviceand the technologies used to implement both client-side andserver-side software components.To assure its scalability, the system has a modular designand each module interacts with the others through layersthat abstract the offered services (access to database, schedulemanagement, rehabilitation sessions management, etc.).Since eFisioTrack is based on communication over theInternet some issues should be born in mind. We are dealingwith clinical data which requires to set policies to preserveits privacy and integrity. Moreover, the system will offer 24 7 365 disponibility but sometimes this is impossibledue to network failures. eFisioTrack can be used in thesecircumstances avoiding loss of information.3.1.1. Objectives Related to Patients and Experts. The systemmust give to patients and experts suitable mechanisms tointeract with each other as if they were one in front of eachother. In the case of patients, at the time they perform theirexercises they should have at their disposal all informationabout the schedule of the rehabilitation plan, a full descriptionabout how to perform each exercise, and real-time feedbackabout their performance. For experts the system shouldgather information about the fulfillment of the plan and thecorrectness of the patients’ performance. This will allow aquick and ubiquitous assessment of the patients’ evolutionand an update of their rehabilitation plans if needed.System’s use will help to increase patients adherence totreatment in two ways. First, since every interaction with thesystem is recorded, if they do not perform the exercises, ifthey perform them at a wrong time or in an erroneous way,the physiotherapist will instantaneously know it. Secondly,the system will avoid cases of forgetting the instructions abouthow to perform the exercises or the schedule of rehabilitationsessions.3.2. eFisioTrack’s Scenario of Use. eFisioTrack will cover allthe experts’ needs, from the first meeting with a patientuntil the end of the rehabilitation process, while reducing thevisits to a point of care and discharging patients from therehabilitation services.To achieve that, we had several meetings with physiotherapists who develop their task at a public hospital, oneof them being expert on adherence to treatment issues.These meetings helped us to understand the functioning ofa physical rehabilitation service and to gain insight of theirneeds.The use of eFisioTrack introduces little changes in experts’current procedures in order to ease the integration of thesystem in their workflow. In (Figure 2) we show the flowdiagram of two of these procedures; now on (Figure 3) wecan see how these procedures’ flow is when using eFisioTrack.Changes between figures are highlighted, and the rest ofprocesses, which stay the same, can be carried out using thesystem as well. It should be pointed out that the use of thesystem let the experts simplify patients supervision process.3. Platform for Physical Telerehabilitation:eFisioTrackOur work aims to build a system whose main objective isto improve the efficiency of physical rehabilitation processesdue to the benefits of outpatient scenarios. In addition, it isdesigned to bridge the gap between patients and physiotherapists, trying to simulate the ideal case of having an expertside by side with patients while they perform the prescribedexercises at home. At the same time, the system is intended tobe helpful for physiotherapists, offering them accurate dataabout patients’ performance allowing them to gain insightabout their evolution.
The Scientific World Journal5Patients supervisionPatients examinationInjuries diagnosedImprovements evaluationNoPhysical evaluationYesYes1st visit?Create historic recordNoNeed for longerrehabilitation?Create a rehabilitation planNoYesPreliminary assessmentsNewrehabilitationneeds?Bandages, manual therapies, and physicalmediumsNoSchedule sessions of rehabilitation
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Research Article eFisioTrack: A Telerehabilitation Environment Based on Motion Recognition Using Accelerometry DanielRuiz-Fernandez, 1 OscarMarín-Alonso, 1 AntonioSoriano-Paya, 1 andJoaquinD.García-Pérez 2 Department of Computer Technology, University of Alicante, Carret
moving diagnostic information rather than the patient. Although a complete diagnosis cannot be performed exclusively through the use of ICT tools, computer-based cation. Home health monitoring services utilise ITC-based technology to monitor patients in their homes by means of devices that measure vital data, such as blood pressure,
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rehabilitation experts. A recent review of telerehabilitation in stroke care found these types of interventions showed promising results for both stroke survivor and carepartner health, including improved quality of life, health status and reduced depression (Johansson et al., 2011). Evidence is evolving for internet-based
(such as the Haptic Master – FCS Robotics, Holland, or the Lokomat made in Germany) may be used. Even for such demanding populations some newer approaches using gaming hardware are emerging. Figure 1a shows a Microsoft Sidewinder joystick (costing
ing cardiac rehabilitation [8]. This literature review aimed to promote telemedicine . while low intensity which scores below 12 on BORG RPE ( 3 on BORG-CR10) is in light criteria or . coronary syndrome, disability, stroke, and on the other hand, improve medication adherence [15-17].
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