porto potenza picena (mc) italy pediatric rehabilitation and … · kinect for xbox one: extracting...

Pediatric Rehabilitation and Technologies

The Gaslini Institute : an Italian experiencewith virtual/augmented reality.

RRSS Second Edition 13-18 May 2019KOS Santo Stefano Rehabilitation Hospital

Porto Potenza Picena (MC) Italy

Paolo MorettiPhysical Medicine and Rehabilitation UnitGaslini Institute Children’s Hospital - Genova

02

Gaslini Childrens’ Hospital is a

national referral center for

complex neonatal, paediatric

and adolescent diseases

requiring specialized medicaland surgical care.

Neurosciences and RehabilitationDepartment

Neurosurgery U.Physical Medicine and Rehabilitation U.

Neurophysiology U.Neuroradiology U.

Child Neuropsychiatric UnitOrthopedic U

Ophtalmology U.Neuropathology U

Pediatric re-habilitation

• Growth and its changing and emerging needs;

• Critical and sensitive periods;

• Motivation;

• Family involvement (family centered approach);

• Personalization of treatments.

Heraclitus 535-475 BC«The only constant is change»

Virtual and augmented reality-based training

• Virtual Reality ( VR ) has emerged as a new approach in rehabilitation treatment of motor and cognitive impairment over the last ten years.

• VR simulates real-life situations in a virtual environment, providing the opportunity to practice cognitive and motor activities that cannot be usually practiced within the clinical environment.

• VR allows dynamic and active interaction since the patient receives real-time multisensory feedback.

• Patients are fully involved in the activities and like in other types of rehabilitation, motivation and participation play a key role in the effectiveness of the rehabilitative treatment.

Serious games and Exergames:diffusion of commercial interactive videogame

consoles for rehabilitation

• Wiihabilitation• Nintendo wiimote and balance board• Sony Eye toy• Microsoft Kinect

• Advantages:• Easy availability • Low costs (cheap)

• Disadvantages:• Not tailored to children with motor

or cognitive impairment• Measurements acquired cannot be

transferred and used elsewhere to assess rehabilitation progress

1305 studies identified 75 selected and analyzed according to the review protocol

General review : 2018 Game Technologies for Pediatric Patients

Predominantly the papers focusedon game technologies as motivators for rehabilitation

activities or as distractors.

Individual games are used significantlymore than multiplayer game

The most recurrent objects of study are:enjoyment 39%pain reduction 31%improvement in mot. function 21%


Line of future work:• focus on kindergarten children (under 6) and

teenagers (over 12).• Psychological, relational and behavioral

impairments to know to what extent games can benefit these illnesses.

• improving physical activities, socialization, and emotion coping.

• Finally: recent but well established technologies as digital tablets, and emerging technology as robot companions .


Literature evidence: top randomized and bottom non-randomised studies. Blue bars, positive change; orange bars, no change.

284 studies identified31 selected and analyzed.

Specific review : 2017 VR Cerebral Palsy

Conclusions:Moderate evidence that VR can be used to improve balance and motor skills, but weak evidence for other parameters.………and there not sufficient evidences to recommend VR for clinical practice in CP and that future research should include well des…RCTs

• 198 studies identifiedand 15 selected and analyzed

• Conclusions : thisreview finds limitedevidence for the effectiveness of video game interventionsfor children with DCD to improve motor outcomes due to limitations in the research includinglow sample sizes and low to moderate methodologicalquality. Furtherresearch is needed to determine the effectof video games or virtual reality interventions on motor outcome in children with DCD.

Specific review : 2019 VR Developmental Coordination Disorder

Augmented Rehabilitation in Interactive/multimodal Environment Lab

• research and development of interactive multimedia and multimodal systems for

rehabilitation;

• flexible and modular open platform prototype for interactive child

rehabilitation exergames with a specific focus on interactive sonification of

motor behaviour.

ARIEL Joint LabIstituto G. Gaslini - UNIGE

Prototype Platform

- Input Modules – General framework and interfaces

Motion Capture Systems: 3D position extraction

Kinect for Xbox One: extracting

2D and 3D coordinates of relevant body joints, and

capturing RGB image, grayscale depth image, and

infrared image of the scene.

Leap Motion: capturing hand and finger movement.

Ethernet Camera: integration with other devices

X-OSC Sensors: extraction of acc. and jerk

Smartphones:

RFID: detection of the presence of a child in a

specific area

Development environment

The End User Interface Designer

The Interactive Storyboard Designer

The Data Manager

Development and programming environmentGrounds on EyesWeb XMI

CULT (Cognitive Upper Limb Trainer)

- Designed to support the recovery of upper limb functions

strength, control of movement, bilateral integration and coordination with

the possibility to add cognitive task for attention, memory and executive functions

The child is in front of a Kinect Box, and moving his arms has to reach and grab

the objects falling down on the screen or on the wall

CERT (Coordination Endurance Rehabilitation Trainer)

Designed to support the recovery of general cardio-respiratory endurance and

global coordination. Sonification encourages the child to keep a rhythm and

coordination (both inter and intra personal). The more limbs or children

movements are synchronized, the more instrumental tracks are added to the audio

output until the original song is fully reconstructed.

HTCT (Head Trunk Control Trainer) Designed to improve control and balance of the head and trunk whilesitting with a simple PC, a sound system, a tablet and a MicrosoftKinectTM.

Ongoing research study with control group: Main research question: evaluate HTCT effectiveness. Secondary research question: value of specific musical contents

UP TO DATE

Results are promising and the developed platform showed good

adaptability to the needs of rehabilitation in children with severe

disability;

Further improvements required in:

- Sensitiveness

- real time response

- ability to detect the child's silhouette even in complex

conditions;

- amount and quality of available musical and graphical content;

- careful design of the space where the platform operates;

Nirvana

Nirvana is an IMMERSIVE REALITY SYSTEM (IVR) for the motor and cognitive rehabilitation

Based on optoelectronic infrared sensors, the patient can simply interact with the virtual environment without the use of a simulator.

The interactive space, with wall and floor projectionsreacts to patient’s actions thanksto a motion-analysis system.

Development and application of rehabilitation protocols to optimizethe use of a simple immersive virtual reality device dedicated to

children with disabilities: A preliminary study

Nirvana

Availability of several types of exercises, with increasing levels of difficulty, according to patient's needs.

No need for visors, gloves or other sensors. Freedom of movement.Also used by patients carrying walking aids (crutches, walkers, tripods) or patients in a wheelchair.

Real time audio-visual stimuli and feedback involve the perceptual-cognitive skills of patients, resulting in motivational training.

Aims of preliminary study and subjects

N PATIENT DIAGNOSIS AGE MOTOR IMPAIRMENT

COGNITIVE IMPAIRMENT

1 Achondroplasia 11 V

2 Polimalf. Synd 17 V V

3 Hemiparesis in stroke

5 V V

4 Diplegia in CP 4 V V

5 CP 4 V V

6 Diplegia in CP 5 V




10 Tetraparesis in CP 10 V V

11 CP 4 V



14 Polimalf.Syndr 7 V V

15 Fibromyalgia 17 V

To evaluate the usefulness and patients’ appreciationof Immersive VirtualReality different typesof exercises in relation to fixedtargets.

15 enrolled patients with motor or motor/cognitive impairments , either followedas DH out-patients or hospitalized in the Physicalmedicine and RehabilitationDepartment, G.GasliniPediatric Institute.Age range was between 3 and 17 years old inclusively.

Material and Methods

-a set of 6 exercises: chosen in relation to the patient’s functional disability characteristics

-Specific target assigned to each patient.

-Evaluation report: for each exercise in order to describe the patient’s performance, verify the correct carrying out of the exercises and to collect data for subsequent analysis.

These patients, in addition to the traditional rehabilitative treatment , underwent complementary training with Nirvana, consisting of :

Material and methods

Simple instructions exercise : «bring the black sheep in the fence»


Cause effect exercise: « guitar»


Cause effect exercise : « find the red balloon»

Results

Age N.Patients Taskunderstanding( >50% ex.)

Usefulness/target

Appreciation

Up to 4 years old

5 60% 60% 80%

5-10 yearsold

7 71% 71% 85%

> 11 yearsold

3 100% 66% 66%

Tab. appreciation, comprehension, usefulness by age

Results

Tab. exerc usefullness in ptwith motor impairment

N.patient

UsefulTreatment

PartiallyUseful

Not Useful

1 X

2 X

3 V

4 V

5 V

6 V

7 V

8 V

9 V

10 V

11 V

12 V

13 X

14 V

15 V

Useful treatment 60%Partially useful treatment 20 %Not useful treatment 20%

Results

N.Patient

Usefultreatment

PartiallyUsefultreatment

Not usefultreatment

1 V

2 X

3 X

4 V

5 V

6 X

Tab. exerc. usefulness in cognitive impairment

Useful treatment 33%Partially useful treatment 17 %Not useful treatment 50 %

Results

Objective N. patients Usefultreatment

Partially useful Not useful

Motor control ( balance, coordination )

11 72% 9% 18%

Strengthimprovement

3 33% 33% 33%

> Attentionspan

6 67% / 33%

Behavioralregulation

5 20% 20% 60%

> Spatialcognition

7 57% 14% 28%

Rate of usefulness in targeted rehabilitation treatment

Discussions• Age groups

• -Children from 5 to 10 years old (85%) appreciated virtual reality- basedtraining. In addition they had the best results in carrying out the requested task ( 71 % ).

• -The comprehension of the tasks has been maximal in the age group > 11 yearsold(100%) , while their appreciation got the lowest value ( 66%)

• Tipology of disability,

• - The session usefulness was greater in children with motor impairmentcompared to children with cognitive impairment ( 60 % versus 33%)

Targets

The most useful treatments regarded these areas:

• 1) Improvement of balance and coordination ( 72%)

• 2) To prolong the attention span (67%)

• 3) Improvement of spatial cognition (57%)

By contrast , the objective that has proved to be the hardest to be pursuedis the behavioural regulation during the test ( 60 % of treatment in this area was considered not useful).

Conclusions• This preliminary study has been conducted with the aim of evaluating the

therapist and patients’s appreciation of this Immersive Virtual Reality training.

We conclude that:

• 1) Nirvana training provides active involvement , dynamic interaction and multi-sensory feedback, arousing patients proactivity and keeping high theirlevel of participation and motivation . For this reason , besides a traditionalrehabilitative treatment, IVR exercises ,in form of games and interestingchallenges , seem to be a useful tool for child rehabilitation.

• 2) Analyzing the data collected, it is pointed out that the tasks in which wefound the best usefulness were those regarding the motor recovery, such asthe improvement of balance and coordination. With regard to the cognitive-behavioural targets, we found usefulness concerning the improvement of the attention span, while weak results in relation to the aspects of behavioral regulation.

Our aim is to enlarge the sample and to evaluate patients in a longerperiod, to confirm the trend for appreciation and usefullness and to test the effectiveness of this interesting tool for rehabilitation therapy .

Thanks for your attention!

GASLINI REHABILITATION TEAM

porto potenza picena (mc) italy pediatric rehabilitation and … · kinect for xbox one: extracting...

Documents