[ieee 2006 international workshop on virtual rehabilitation - new york, ny, usa ()] 2006...

Abstract—Rehabilitative interventions may be provided to disabled people at home by means of telerehabilitation. We evaluated the effects of a telerehabilitation program designed for ameliorating motor deficits in post-stroke patients with arm impairment. We also compared the effects of home-based traditional rehabilitation provided by physiotherapists. We selected 24 patients suffering from mild/intermediate arm motor impairments due to a long-lasting ischemic stroke in the territory of middle cerebral artery. A new virtual reality (vr) based system working on Internet connections provided adequate motor tasks to the patients from a remote rehabilitation facility. Both, the home-based traditional and the telerehabilitation programs, lasted four weeks. Before, at the end of the therapies and one month thereafter, we assessed the motor deficit and the functional activities of the upper extremity with the Fugl-Meyer scale and the Abilhand scale. In addition, the spasticity of the arm was determined with the Ashworth scale. Finally, we examined at the same evaluation times the mean linear velocity and the duration of 30 consecutive reaching movements. Both the rehabilitative therapies improved significantly the Fugl-Meyer mean score and the Abilhand scale score. The clinical outcomes were not different between the two groups. In the telerehabilitation treated group, mean duration and mean velocity of the reaching movements improved by 20.5 % and by 16.3%, respectively. These results supported the observations that some post stroke patients may benefit from a home-based telerehabilitation program to improve their motor deficits. This fact may favor an early discharge from hospital and have beneficial effects on the quality of life. In addition, telerehabilitation program may spare the available resources

Manuscript received April 7, 2006. This work was supported in part by

Italian Health Ministry under Grant Budget R0202, year 2002. L. P. is with the Department of Neurorehabilitation, I.R.C.C.S. San

Camillo Hospital, via Alberoni 70, 30011 Lido di Venezia, Italy. (phone: 0039 041 2207214; fax: 0039 041 2207214; e-mail: [email protected]).

P. T. is with the Department of Neurorehabilitation, I.R.C.C.S. San Camillo Hospital, via Alberoni 70, 30011 Lido di Venezia, Italy. (e-mail: [email protected]).

F. C. is with the Department of Rehabilitation, S. Bortolo Hospital, Vicenza, Italy ([email protected]).

M. Z. is with the Department of Rehabilitation, Foligno Hospital, Perugia, Italy. ([email protected]).

F. P. is with the Department of Neurorehabilitation, I.R.C.C.S. San Camillo Hospital, via Alberoni 70, 30011 Lido di Venezia, Italy. ([email protected]).

M. A. is with the Department of Neurorehabilitation, I.R.C.C.S. San Camillo Hospital, via Alberoni 70, 30011 Lido di Venezia, Italy. ([email protected]).

C. Z. is with the Department of Neurorehabilitation, I.R.C.C.S. San Camillo Hospital, via Alberoni 70, 30011 Lido di Venezia, Italy. ([email protected]).

A. T. is with the Department of Neurorehabilitation, I.R.C.C.S. San Camillo Hospital, via Alberoni 70, 30011 Lido di Venezia, Italy. ([email protected]).

M. D. is with the Department of Neurology and Psychiatry University of Padova, via Giustiniani 5, 35100 Padova, Italy. ([email protected]).

since allows physiotherapists and physicians to rehabilitate and monitor the patients remotely from rehabilitation facilities.

I. INTRODUCTION ELEMEDICINE represents the ongoing next step of the digital revolution in the medical field allowing the

possibility of sharing data, providing diagnosis and therapy remotely.

Telerehabilitation is the remote delivery of a variety of rehabilitative services through telecommunication technology, which means the exploitation of patient assessment functioning, patient clinical management at distance and follow up, managing therapies remotely, tele-counseling, selecting the patient best set of care at home or in the rehabilitation facilities and educating professionals and caregivers.

In particular, managing therapies remotely represents the opportunity to deliver therapeutic interventions at distance for subjects with disabilities due to various injuries [1]-[4].

In this regard, the rehabilitation of neurological lesions remotely allow the increase of the therapeutic sessions which in turn could promote the patient recovery especially when long-term restorative therapy are required. On the other hand, several National Health System guidelines recommend reduction in patient’s length of stay in hospital in order to achieve economic savings. Telerehabilitation may reconcile the above issues assisting home compromised people and avoiding unnecessary hospital admissions. Therefore, telerehabilitation may attend to patient’s needs sparing health resources.

Few years ago, we performed an initial study connecting five post-stroke patients treated at their home by means of a vr based prototypal system working on digital lines [5]. That research reported an improvement of patient arm motor performance after the telerehabilitation trial and a positive tele-interaction between the patient and the therapist. In order to confirm these preliminary evidences, we conducted a controlled study with a larger sample of post-stroke patients, recruited in three rehabilitation centers. In this study we used a new vr-based system working on low-cost Internet connections.

II. SUBJECTS AND METHODS The study group consisted of 24 patients, 14 male and 10

female, mean age 65.8 ± 7.8 years, suffering from mild to intermediate arm motor impairment (according to the Fugl-Meyer Upper Extremity sub-score ranging from 30 to 55).

Patients were affected by a single ischemic stroke in the

Post-stroke arm motor telerehabilitation web-based Lamberto Piron, Paolo Tonin, Feliciana Cortese, Mauro Zampolini, Francesco Piccione, Michela

Agostini, Carla Zucconi, Andrea Turolla and Mauro Dam.

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1451-4244-0280-8/06/$20.00 ©2006 IEEE

territory of the left (12 subjects) and the right (12 subjects) middle cerebral artery and they were recruited six to twenty-four months after the ischemic event (11.8 ± 4.1 months). Subjects with clinical evidence of cognitive impairment, apraxia, neglect and language disturbances interfering with verbal comprehension were excluded from the study.

The twenty-four selected patients were randomly treated at home with the telerehabilitation system (12 subjects, study group) or with home-based conventional physiotherapy (12 subjects, control group).

Both treatment lasted one hour a day, five days weekly for one month.

Before, at the end of the therapies and one month thereafter, we assessed the motor deficit and the functional activities of the upper extremity with the Fugl-Meyer scale for the upper extremity (Fugl-Meyer UE) and the Abilhand scale [6], [7]. In addition, the spasticity of the arm was determined with the Ashworth scale. Finally, we examined at the same evaluation times the mean linear velocity and the duration of 30 consecutive reaching movements. The examining neurologist was not made aware of the treatment administered to the patients.

This protocol was approved by the local ethical committee. A written consent was obtained from all participants.

The telerehabilitation system was the VRRS.net® (Khymeia Ltd., Padova, ITALY) which consisted of two dedicated PC-based workstations, one located at the patient’s domicile and the second at the rehabilitation hospital. The VRRS.net® generated a vr environment for the patients motor tasks coupled with a videoconference tool. The connection procedure was based on a TCP/IP protocol through a broad-band access (Asymmetric Digital Subscriber Line, ADSL) to Internet. A static IP (Internet Protocol) address was assigned to both systems by the Internet provider administrator in order to have an easier and more stable connection. The data flow (rehabilitative and

videoconferencing data) was sustained by the Internet connection. A VRRS.net® integrated high-quality videoconferencing permitted the remote control of the patients video-camera mobility in order to observe the patients movement during the rehabilitation tasks. Fig. 1

The VRRS.net® was equipped with a 3D motion tracking system (Polhemus 3Space Fastrack, Vermont, U.S.A.) to record the arm movements by a magnetic receiver attached to a real object. The system transformed the receiver in a virtual image (virtual object) that changed position on the screen according to the receiver motion.

Five virtual tasks, comprising of simple arm movements, were created for training patient’s left or right arm deficits. During the rehabilitation session, the patient moved the real object following the trajectory of the corresponding virtual object displayed on the computer screen in accordance to the requested virtual task. Fig. 2

The subject could see not only his movement but also the correct trajectory prerecorded in the virtual scene. In

addition, the therapist provided the patient with information about the task correctness through the videoconference system.

Before entering into the study, the patients were trained to utilize the computerized rehabilitation system, to properly locate the magnetic receiver, to adequately execute the requested motor tasks.

The Wilcoxon test was used to determine the statistical significance of the differences in the Fugl-Meyer UE mean score, the Abilhand scale score, the Ashworth scale, the mean duration and the velocity of reaching movements before and after the therapy.

Statistical significance was considered at p ≤ 0.05.

III. RESULTS All patients completed the study. They did not experience

major problems in handling the system. The video-

Fig. 2. A representative “virtual” reaching motor task displayed on the patient PC monitor: The patient, moving the receiver (corresponding to the virtual red sphere) with the affected arm, has to reach the center of a yellow virtual donut from a starting position (yellow wireframe cube) according to the displayed trajectory.

Fig. 1. The therapist telerehabilitation equipment (VRRS.net®). The therapist can see the virtual motor task and the patient performance in the same screen during the tele-interaction.

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conferencing provided a complete assistance by the physiotherapist, who eventually could control remotely all the commands.

Sometimes, a reduction of the broadband was reported with a slowing of the data flow and with blurring of the images. Seldom, there was an unexpected interruption of the connection between the two workstations.

Table I depicts motor and functional scores of the affected arm of the 12 telerehabilitation group patients before, at the end of the treatment and one month thereafter.

Table II represents the same scale scores for the control group patients.

The therapy significantly improved all the clinical scales scores in the study group, while in the control group the Ashworth scale score did not result significantly ameliorated after treatment.

In the study group mean duration and mean velocity of the reaching movements improved by 20.5 % and by 16.3%, respectively.

IV. DISCUSSION In this study we compared the effects of a home-based

rehabilitation therapy to an innovative rehabilitative

technique based on low-cost Internet connections. Both therapies were comparably effective in the treatment

of arm motor deficits due to a ischemic stroke. These results

confirmed the previous evidences emerged in a smaller group of post-stroke subjects.5

We also confirmed that telerehabilitation represents a feasible method to treat stroke motor impairments without major technical problems or handling system difficulties by the patients [4], [5].

In addition, the artificial interaction patient-therapist didn’t interfere with the process of motor recovery, as demonstrated from the progress of the clinical scale scores.

The improvement of cinematic measures paralleled the clinical motor progress observed in the vr treated patients. [8], [9]. These results may underline the fact that cinematic measures of simple movements are transmissible and may provide a scoring of the patient motor performance, without the requirement of a physician evaluation.

We do not know exactly the mechanism underlining the motor amelioration observed in the telerehabilitation treated patients by means of VR. We have previously presumed that vr may provide adequate feedbacks (such as knowledge of performance and of results) that represent the major determinants promoting the re-learning of compromised movements [9]-[11]. However, the presence and control of the physiotherapist, at the patients side, may also be contributory probably because the patients may feel more secure and psychologically supported. On the other hand, during the telerehabilitation sessions, the patients basically work with a machine and the physiotherapists only remotely interact with them. These observations may lessened the therapeutical relevance of the physical presence of the therapist and may reinforce the hypothesis that the adequate feedbacks supplied along with the display of specific tasks may represent the key factor in the processes of motor recovery.

In conclusion, this study further confirm the observations that, at least, some post stroke patients may undergo a telerehabilitation program to improve from their motor deficits. This fact may favor an early discharge from hospital and a subsequent rehabilitative intervention at home, which do not compromise clinical outcomes after a stroke and may have beneficial effects on the quality of life.

Finally, telerehabilitation program may spare the available resources since allows health professionals to rehabilitate and monitor the patients without any displacement from their working location.

REFERENCES [1] R. B. Burns, D. Crislip, P. Daviou, A. Temkin, S. Vesmarovich, J.

Anshutz. “Using telerehabilitation to support assistive technology”. Assistive Technology; vol. 10, pp 126-133, 1998.

[2] D. J. Reinkensmeyer, C. T. Pang, J. A. Nessler, C. C. Painter. “Web-based telerehabilitation for the upper extremity after stroke”. IEEE Trans Neural Syst Rehabil Eng, vol. 10, pp 102-08, 2002.

[3] G. Burdea, V. Popescu, V. Henz, K. Colbert. “Virtual reality based orthopedic telerehabilitation.” IEEE Trans Neural Syst Rehabil Eng, vol. 8, pp 430-32, 2000.

[4] L. Piron, P. Tonin, A. M. Atzori, E. Zanotti, E. Trivello, M. Dam. “Virtual environment system for motor tele-rehabilitation.” In Medicine Meets Virtual Reality 2002, J. D. Westwood, H. F. Hoffman, R. A. Robb, Stredney D, Amsterdam, IOS Press, 2002, pp 355-61.

TABLE II

FM UE = Fugl-Meyer Upper Extremity score; Abil= Abilhand scale

score; Ascw UE = Ashworth Upper Extremity scale score.

TABLE I

FM UE = Fugl-Meyer Upper Extremity score; Abil= Abilhand scale

score; Ascw UE = Ashworth Upper Extremity scale score.

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[5] L. Piron, P. Tonin, E. Trivello, L. Battistin, M. Dam. “Motor tele-rehabilitation in post-stroke patients.” Medical Informatics & The Internet in Medicine, vol. 29, pp 119-125, 2004.

[6] A. R. Fugl-Meyer, L. Jaasko, L. Leyman, S. Olsson, S. Steglind. “The post-stroke hemiplegic patient. A method for evaluation of physical performance.” Scand J Rehab Med. Vol. 7, pp 13-31, 1975.

[7] M. Penta, L. Tesio, C. Arnould, A. Zancan, J. L. Thonnard. “The ABILHAND Questionnaire as a Measure of Manual Ability in Chronic Stroke Patients Rasch-Based Validation and Relationship to Upper Limb Impairment.” Stroke, vol. 32, pp 1627-1634, 2001.

[8] M. C. Cirstea, M. F. Levin “Compensatory strategies for reaching in stroke.” Brain, vol. 123, pp 940-53, 2000.

[9] L. Piron, P. Tonin, F. Piccione, V. Iaia, E. Trivello, M. Dam. “Virtual environment training therapy for arm motor rehabilitation” Presence, vol. 6 (14), pp 732-740, 2005.

[10] E. Todorov, R. Shadmehr, E. Bizzi. “Augmented feedback presented in a virtual environment accelerates learning of a difficult motor task.” J Motor Behav., vol. 29, pp 147-58, 1997.

[11] M. Holden, E. Todorov, J. Callahan, E. Bizzi. “Virtual Environment training improves motor performance in two patients with stroke: case report”. Neurology Report, vol. 23, pp 57-67.

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