Raymond Holt

Engaging children in healthcare technology design: developing rehabilitation technology for children with cerebral palsy

This paper presents a case study of users’ involvement in the design and evaluation of two devices for upper limb rehabilitation for children with cerebral palsy to use in their homes. The devices comprise a computer game and a force feedback interface, designed to stimulate children with cerebral palsy to undertake fun arm exercises that are beneficial in terms of improving overall functional use of their impaired arm. This device was developed for children using a combination of informal and formal user-centred design methods. The methods used include standard questionnaires, interviews, a modified peer tutoring process and a comparative method, and have been applied to the iterative design of both the hardware and software components of the rehabilitation systems. Thirty-seven non-disabled children and 15 children with cerebral palsy in the 5–12-year-old age group were involved in the evaluation, held at six local primary schools. Prototypes of the final design were used by 18 patients with cerebral palsy for approximately 4 weeks as a therapeutic intervention. To evaluate the designs, qualitative and questionnaire-based opinion was sought from these children, and their parents, at the end of the intervention. An evaluation of the methodologies employed is presented.

HOME-BASED COMPUTER-ASSISTED UPPER LIMB EXERCISE FOR YOUNG CHILDREN WITH CEREBRAL PALSY: A FEASIBILITY STUDY INVESTIGATING IMPACT ON MOTOR CONTROL AND FUNCTIONAL OUTCOME

OBJECTIVE We developed a home-based rehabilitation exercise system incorporating a powered joystick linked to a computer game, to enable children with arm paresis to participate in independent home exercise. We investigated the feasibility and impact of using the system in the home setting. METHODS Eighteen children with cerebral palsy (median age 7.5 years, age range 5-16 years) were recruited from local National Health Service and the exercise system was installed in their home for approximately 4 weeks. Baseline and post-intervention assessments were taken: Canadian Occupational Performance Measure (COPM); kinematic measurement of movement quality (indexed by duration and smoothness) measured using a motion tracking system when performing a standardized computer task. RESULTS The system was used for a median time of 75 min (interquartile range (IQR) 17-271), equating to 606 outward and 734 inward movements. Pre-COPM, (median 4.2); post-COPM (median 6.0); obs=34; z=3.62, p<0.01). Kinematic analysis of pre- and post-intervention movements on the standardized task showed decreased duration and increased smoothness. CONCLUSION Some improvements in self-reported function and quality of movement are observed. This pilot study suggests that the system could be used to augment home-based arm exercise in an engaging way for children with cerebral palsy, although a controlled clinical trial is required to establish clinical efficacy. The feasibility of this technology has been demonstrated.

Dual robot system for upper limb rehabilitation after stroke: The design process

Abstract Stroke is the most common cause of severe disability in the UK. Arm impairment is common and recovery is partly dependent on the intensity and frequency of rehabilitation intervention. However, physical therapy resources are often limited, so methods of supplementing traditional physiotherapy are essential. Robot assisted physiotherapy is one way to increase the duration patients spend participating in rehabilitation activities. A single robot system has been developed at the University of Leeds that actively assists patients undertaking therapeutic movements in a three-dimensional workspace. However, using only a single point of contact at the wrist to assist with therapeutic reaching movements does not allow control or support of the more proximal joints of the upper limb. This could lead to discomfort during assisted exercise. In addition, the design suffers from a restrictive workspace, limiting the range of therapeutic exercise that can be undertaken. To address these limitations, the intelligent Pneumatic Arm Movement system has been developed. A major aspect of the development process has been the continual involvement of physiotherapists and stroke patients; the end users of the system. Through inclusion of these stakeholders, a system has been developed that satisfies their requirements for workspace, comfort, safety, and ease of use.

The engagement of children with disabilities in health-related technology design processes: identifying methodology.

Purpose. This review aims to identify research methodology that is suitable for involving children with disabilities in the design of healthcare technology, such as assistive technology and rehabilitation equipment. Method. A review of the literature included the identification of methodology that is available from domains outside of healthcare and suggested a selection of available methods. Results. The need to involve end users within the design of healthcare technology was highlighted, with particular attention to the need for greater levels of participation from children with disabilities within all healthcare research. Issues that may arise when trying to increase such involvement included the need to consider communication via feedback and tailored information, the need to measure levels of participation occurring in current research, and caution regarding the use of proxy information. Additionally, five suitable methods were highlighted that are available for use with children with disabilities in the design of healthcare technology. Conclusion. The methods identified in the review need to be put into practice to establish effective and, if necessary, novel ways of designing healthcare technology when end users are children with disabilities.

User involvement in developing Rehabilitation Robotic devices: An essential requirement

Treatment from a trained therapist is an important aspect of stroke rehabilitation, but resource limits mean that not all stroke patients receive the treatment that they require. The iPAM (Intelligent Pneumatic Arm Movement) is a robotic system that aims to provide more time-efficient rehabilitation therapy. To make sure this really addresses the needs of therapists and patients, the iPAM development has involved significant input from both parties throughout its development. However, despite the generally accepted importance of user involvement in the development of rehabilitation robotics, there is still a lack of published literature in this area, and most of the reported cases only seek user opinion once a device has been developed. This paper reviews existing literature on user involvement, and discusses the approach adopted in the iPAM project. Feedback from the user tests is presented, along with a discussion of its implications for future development of the system, and the importance of involving users in all stages of the development process.

Predicting the Effect of Surface Texture on the Qualitative Form of Prehension

Reach-to-grasp movements change quantitatively in a lawful (i.e. predictable) manner with changes in object properties. We explored whether altering object texture would produce qualitative changes in the form of the precontact movement patterns. Twelve participants reached to lift objects from a tabletop. Nine objects were produced, each with one of three grip surface textures (high-friction, medium-friction and low-friction) and one of three widths (50 mm, 70 mm and 90 mm). Each object was placed at three distances (100 mm, 300 mm and 500 mm), representing a total of 27 trial conditions. We observed two distinct movement patterns across all trials—participants either: (i) brought their arm to a stop, secured the object and lifted it from the tabletop; or (ii) grasped the object ‘on-the-fly’, so it was secured in the hand while the arm was moving. A majority of grasps were on-the-fly when the texture was high-friction and none when the object was low-friction, with medium-friction producing an intermediate proportion. Previous research has shown that the probability of on-the-fly behaviour is a function of grasp surface accuracy constraints. A finger friction rig was used to calculate the coefficients of friction for the objects and these calculations showed that the area available for a stable grasp (the ‘functional grasp surface size’) increased with surface friction coefficient. Thus, knowledge of functional grasp surface size is required to predict the probability of observing a given qualitative form of grasping in human prehensile behaviour.

A new tool for assessing head movements and postural sway in children

Current methods of measuring gross motor abilities in children involve either high-cost specialist apparatus that is unsuitable for use in schools, or low-cost but nonoptimal observational measures. We describe the development of a low-cost system that is capable of providing high-quality objective data for the measurement of head movements and postural sway. This system is based on off-the-shelf components available for the Nintendo Wii: (1) The infrared cameras in a pair of WiiMotes are used to track head movements by resolving the position of infrared-emitting diodes in three dimensions, and (2) center-of-pressure data are captured using the WiiFit Balance board. This allows the assessment of children in school settings, and thus provides a mechanism for identifying children with neurological problems affecting posture. In order to test the utility of the system, we installed the apparatus in two schools to determine whether we could collect meaningful data on hundreds of children in a short time period. The system was successfully deployed in each school over a week, and data were collected on all of the children within the school buildings at the time of testing (N = 269). The data showed reliable effects of age and viewing condition, as predicted from previous small-scale studies that had used specialist apparatus to measure childhood posture. Thus, our system has the potential to allow screening of children for gross postural deficits in a manner that has never previously been possible. It follows that our system opens up the possibility of conducting large-scale behavioral studies concerning the development of posture.

Grasping the changes seen in older adults when reaching for objects of varied texture.

Old age is associated with reduced mobility of the hand. To investigate age related decline when reaching-to-lift an object we used sophisticated kinematic apparatus to record reaches carried out by healthy older and younger participants. Three objects of different widths were placed at three different distances, with objects having either a high or low friction surface (i.e. rough or slippery). Older participants showed quantitative differences to their younger counterparts – movements were slower and peak speed did not scale with object distance. There were also qualitative differences with older adults showing a greater propensity to stop the hand and adjust finger position before lifting objects. The older participants particularly struggled to lift wide slippery objects, apparently due to an inability to manipulate their grasp to provide the level of precision necessary to functionally enclose the object. These data shed light on the nature of age related changes in reaching-to-grasp movements and establish a powerful technique for exploring how different product designs will impact on prehensile behavior.

Involving children in the development of assistive technology devices

Purpose. To investigate the implementation of a web-based survey for involving children in the design of assistive technology devices within the primary school environment. Method. Children were recruited within their normal school environment. They completed tasks within the survey that sought to gather their personal preferences about assistive technology devices. From six primary schools, 257 children (mean age = 9 years and 8 months, SD = 1.51; 123 males, 134 females) including children with cerebral palsy (N = 11), varying levels of deafness (N = 7), global developmental delay (N = 2) and Downs syndrome (N = 1) participated. Observations were taken whilst the children completed the survey tasks. Results. All children were able to complete the tasks from the survey, although children with disabilities had higher completion times and most required a form of assistance from support assistants and/or sign language interpreters. Conclusions. The use of the web-based survey provided a novel means with which to involve children with and without disabilities in the design of assistive technology devices within a primary school environment. In order for the survey to be utilised more widely, issues that arose when involving children with disabilities need to be addressed.

Intraindividual variability and falls in older adults.

Objective: We investigated whether a simple measure of reaction time (RT) intraindividual variability (IIV) was associated with falls in older adults. Falls and fall-related injuries represent a major cost to health care systems, it is therefore critically important to find measures that can readily identify older adults at greater risk of falling. Method: Cognitive and motor function were investigated in 108 adults aged 53 to 93 years (M = 73.49) recruited across the local community and hospital outpatient department. Forty-two participants had experienced either an injurious fall, or multiple falls, in the previous 2 years. Results: Logistic regression suggested that fallers could be distinguished from nonfallers by greater medication use, IIV, postural sway, weaker grip strength and slower gait speed. Structural equation models revealed that IIV was predictive of falls via the mediating variable of motor function (e.g., gait). IIV also predicted higher order cognition (executive function) but higher order cognitive function did not uniquely predict falls or account for the associations between IIV and falls. Conclusions: These findings indicate that IIV measures capture important aspects of cognitive and motor decline and may have considerable potential in identifying older adults at risk of falling in health care and community settings.