Correspondence to

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MaureenK.Holden*ThomasA.DyarDepartmentofBrainandCognitiveScienceandTheMcGovernInstituteforBrainResearchandClinicalResearchCenterMassachusettsInstituteofTechnologyCambridge,Massachusetts*Correspondencetoholden@mit.edu

LeeSchwammClinicalResearchCenterMassachusettsInstituteofTechnologyCambridge,MassachusettsandDepartmentofNeurologyMassachusettsGeneralHospitalandHarvardMedicalSchoolBoston,Massachusetts

EmilioBizziDepartmentofBrainandCognitiveScienceandTheMcGovernInstituteforBrainResearchandClinicalResearchCenterMassachusettsInstituteofTechnologyCambridge,Massachusetts

Presence,Vol.14,No.2,April2005,214–233©2005bytheMassachusettsInstituteofTechnology

Virtual-Environment-BasedTelerehabilitationinPatientswithStroke

AbstractWedescribeatelerehabilitationsystemthathasbeendevelopedinourlaboratory,andinitialresultsfollowinguseofthesystemon2patientswithstroke.Thesystemallowsatherapistinaremotelocationtoconducttreatmentsessions,usingavirtual-environment-basedmotor-trainingsystem,withapatientwhoislocatedathome.Thesystemconsistsofapatientcomputerwithmotion-captureequipmentandvideocamera,atherapistcomputerwithvideocamera,andvirtual-environmentsoftwarethatissynchronizedoverahigh-speedInternetconnection.Thepatient’smovementsareanimatedwithinthecontextofavirtualsceneassheattemptstoimitateaprerecordedmovement,whilethetherapistcandirectandmonitortheactivityinrealtime,asdisplayedintheanimatedvirtualsceneandviavideoconfer-ence.Thedesign,technicaltesting,andclinicalfeasibilitytestingofthesystemarereported.Resultsfromthefirst2strokepatientstousethesystemindicatethatpatientsmadesignificantgainsinupper-extremityfunctionasmeasuredbystandardclinicaltestsandbytheirsubjectivereport.Aswell,bothpatientsdemonstratedgainsonquantitativekinematicmeasuresofupper-extremitytrajectoriesperformedintherealworld,indicatingtransferoftrainingfromVEtoreal-worldperformance.

1IntroductionThehealthcaredeliverysystemintheUnitedStateshasbeenundergo-ingsignificantchangeinrecentyears.Duetotheshorteningofhospitalstays,patientsarereturningtotheirhomesfollowingdisablingevents,suchasstroke,soonerthaninthepast.Oftentheydosoatlowerfunctionallevels,andwithsignificantneedforcontinuedrehabilitation(Dobkin,1995).Thisneedistypicallymetthroughhomecareoroutpatienttherapyservices,butoftentheseservicesarelimitedinduration.Manypatientsalsoencountertransportationproblemsinaccessingoutpatienttherapy,especiallyifdependentonotherstodrivethemtoappointments.Othersexperienceextremefatiguefromlongcommutesintandemwiththerapysessions.Thesepatientpopulationscouldbenefitgreatlyfromasystemthatallowsatherapisttoproviderehabilitationservicesfromaremotelocation,whilethepatientremainsintheirhomesetting.Inadditiontothisneedfornewhealthcaredeliverymodelsinrehabilita-tion,theneedfornewmethodsinstrokerehabilitationispressing(NationalCenterforMedicalRehabilitationResearch,1993).Thesharpdeclineinstrokemortality,duetoimprovedmedicalcare,hasresultedinalargernumber

214PRESENCE:VOLUME14,NUMBER2ofsurvivorsinrecentyears.Manyofthesesurvivorsareleftwithresidualdisability.Infact,strokeistheleadingcauseofdisabilityintheUnitedStates,resultinginanestimatedannualcostof$30billiondollars(Dobkin,1995).Toaddressthisneedfornewtreatmentap-proaches,wehavedevelopedanovelmotor-trainingsystemthatmakesuseofavirtualenvironment(VE)toassistrehabilitation(Holden,2001;Holden&Dyar,2002).RecentlywehaveexpandedthefunctionalityoftheVEsystemtoincludehome-basedtelerehabilitationcapability(Holden,Dyar,Schwamm,&Bizzi,2003).Ourhopeisthatwecanenablemorestrokepatientstomakeuseoftheirlatentpotentialformotorrecoverythroughtheuseofbothanoveltreatmentapproach(VE)andanoveldeliverysystem(telerehabilitation).Afewothergroupshavereportedonthedevelop-mentoftelerehabilitationsystems.Burdeaandcol-leagueshavedevelopedaVE-basedtelerehabilitationsystemthatfocusesonhandrehabilitationusingforcefeedback,andtestedthissystemonorthopedicpa-tients(Burdea,Popescu,Hentz,&Colbert,2000;Popescu,Burdea,Bouzit,&Hentz,2000).Reinkens-meyer,Pang,Nessler,andPainter(2002)havedevel-opedaWeb-basedtelerehabilitationsystemthatthepatientcanaccessindependently,andwithwhichhe/shecanpracticesimplemovementsusinganadaptedcomputerjoystickwithforcefeedback.Thesesystemsappeartobedesignedmainlyforindependentworkbythepatient,withthenetworkingcomponentbeingusedtosenddatatothetherapistforlaterevaluation.Althoughavideoconferencinglinkisincludedinoneofthesesystems(Popescuetal.,2000),itwastooslowtosupportreal-timeinteractivetherapy.Aspres-entlyconfigured,onlyhighlyconstrainedmovementsinaverysmallworkspacecanbepracticedusingthesesystems.Bothsystemshaveprovenfeasibleinpilottestingonasinglepatient.However,neitherofthepatientswasreportedtohavesignificantimprovementonstandardclinicaltestsofupper-extremity(UE)functionfollowingtraining,thoughsomechangesinforceproduction(Burdeaetal.2000;Popescuetal.,2000),movement,andspeed(Reinkensmeyeretal.,2002)onselectedtestitemswereseen.Piron,Tonin,Atzori,Trivello,andDam(2003),workinginItaly,havereportedgreatersuccesswithhome-basedtelere-habilitation,findingasignificantimprovementinthemeanvaluesforclinicalandVEtrajectorymeasuresforthefirst5subjectstested,following4weeksofdailytherapyviatelerehabilitation.TheirVEsoftwarewasdevelopedinourlaboratoryatMIT,andisapre-cursortooursystem,havingasimilararchitecturewithsynchronizedVEatboththepatientandthera-pistlocations.TheirInternetconnectionconsistedofmultipleIntegratedServicesDigitalNetwork(ISDN)linesprovidingbidirectionalbandwidthof512kbps,obtainedthroughaspecialarrangementwiththelocalItalianphonecompany.AWeb-basedtelemonitoringsystemforanklerehabilitationhasalsobeenreported(Deutsch,Boian,Lewis,&Burdea,2003;Lewis,Boian,Burdea,&Deutsch,2003).ThisworkhasshownthefeasibilityofusingWeb-basedtelerehabili-tationforaclinic-to-clinic(vs.ahome-to-clinic)setup.Incontrasttothesystemsdescribedbyothers(Burdeaetal.,2000;Popescuetal.,2000;Reinkens-meyeretal.,2002),ourtelerehabilitationsystem(Holdenetal.,2003;Dyar&Holden,2004;Pironetal.,2003)canprovidereal-timehome-basedinteractivetreatmentsessionswithsimultaneousVEandvideocon-ferencing,andcanbeusedtotrainawidevarietyofmovementsinanypartoftheUEworkspace.Inthispaperwedescribeinitialresultsfromanongoingstudydesignedtodevelopandtesttheclinicalfeasibilityofthesystem.Wedescribethesystemdesignandchallengesencounteredduringdeploymentofthesystemforhome-baseduse.Aswell,wedescribethedetailsoftheVEtreatmentsused,andtheresultsobtainedwithourfirst2patients.Bothhavedemonstratedclinicallymean-ingfulgainsonavarietyofoutcomemeasures.