Development and evaluation of a new telerehabilitation system based on VR technology using multisensory feedback for patients with stroke
Identifieur interne : 003E21 ( Ncbi/Merge ); précédent : 003E20; suivant : 003E22Development and evaluation of a new telerehabilitation system based on VR technology using multisensory feedback for patients with stroke
Auteurs : Norio Kato ; Toshiaki Tanaka ; Syunichi Sugihara ; Koichi ShimizuSource :
- Journal of Physical Therapy Science [ 0915-5287 ] ; 2015.
Abstract
[Purpose] The purpose of this study was to develop a new telerehabilitation system based on VR technology for training of paralyzed upper and lower extremities and poor balance in patients with stroke. Moreover, the effectiveness of the system was verified by analysis of the recovery of these patients. [Subjects] Five healthy persons and five people with motor paralysis, caused by cerebrovascular disease, participated. [Methods] The features of our system are as follows: (1) Our system can train upper and lower limbs and balancing with 3D images. (2) A Kinect® is used for user posture detection. (3) A vibrator is used for feedback to a sensory receptor in order to promote the learning effect of motion. Upper limb and balance training were conducted in this study. [Results] The time necessary for the upper limb and balance training tasks was shortened for the participants with disabilities. The joint angle for the participants with disabilities tended to equate to that of the healthy participants over time. Moreover, our system had no side effects. [Conclusion] These points suggest that our system is effective and safe. The user interface and assessment of the conditions of patients from a distance should be studied in the future.
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DOI: 10.1589/jpts.27.3185
PubMed: 26644671
PubMed Central: 4668162
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<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Development and evaluation of a new telerehabilitation system based on VR
technology using multisensory feedback for patients with stroke</title><author><name sortKey="Kato, Norio" sort="Kato, Norio" uniqKey="Kato N" first="Norio" last="Kato">Norio Kato</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Tanaka, Toshiaki" sort="Tanaka, Toshiaki" uniqKey="Tanaka T" first="Toshiaki" last="Tanaka">Toshiaki Tanaka</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Sugihara, Syunichi" sort="Sugihara, Syunichi" uniqKey="Sugihara S" first="Syunichi" last="Sugihara">Syunichi Sugihara</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Shimizu, Koichi" sort="Shimizu, Koichi" uniqKey="Shimizu K" first="Koichi" last="Shimizu">Koichi Shimizu</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">26644671</idno><idno type="pmc">4668162</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4668162</idno><idno type="RBID">PMC:4668162</idno><idno type="doi">10.1589/jpts.27.3185</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000243</idno><idno type="wicri:Area/Pmc/Curation">000243</idno><idno type="wicri:Area/Pmc/Checkpoint">000642</idno><idno type="wicri:Area/Ncbi/Merge">003E21</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Development and evaluation of a new telerehabilitation system based on VR
technology using multisensory feedback for patients with stroke</title><author><name sortKey="Kato, Norio" sort="Kato, Norio" uniqKey="Kato N" first="Norio" last="Kato">Norio Kato</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Tanaka, Toshiaki" sort="Tanaka, Toshiaki" uniqKey="Tanaka T" first="Toshiaki" last="Tanaka">Toshiaki Tanaka</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Sugihara, Syunichi" sort="Sugihara, Syunichi" uniqKey="Sugihara S" first="Syunichi" last="Sugihara">Syunichi Sugihara</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author><author><name sortKey="Shimizu, Koichi" sort="Shimizu, Koichi" uniqKey="Shimizu K" first="Koichi" last="Shimizu">Koichi Shimizu</name><affiliation><nlm:aff>NONE</nlm:aff></affiliation></author></analytic><series><title level="j">Journal of Physical Therapy Science</title><idno type="ISSN">0915-5287</idno><idno type="eISSN">2187-5626</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><p>[Purpose] The purpose of this study was to develop a new telerehabilitation system based
on VR technology for training of paralyzed upper and lower extremities and poor balance in
patients with stroke. Moreover, the effectiveness of the system was verified by analysis
of the recovery of these patients. [Subjects] Five healthy persons and five people with
motor paralysis, caused by cerebrovascular disease, participated. [Methods] The features
of our system are as follows: (1) Our system can train upper and lower limbs and balancing
with 3D images. (2) A Kinect<sup>®</sup> is used for user posture detection. (3) A
vibrator is used for feedback to a sensory receptor in order to promote the learning
effect of motion. Upper limb and balance training were conducted in this study. [Results]
The time necessary for the upper limb and balance training tasks was shortened for the
participants with disabilities. The joint angle for the participants with disabilities
tended to equate to that of the healthy participants over time. Moreover, our system had
no side effects. [Conclusion] These points suggest that our system is effective and safe.
The user interface and assessment of the conditions of patients from a distance should be
studied in the future.</p></div></front><back><div1 type="bibliography"><listBibl><biblStruct></biblStruct><biblStruct><analytic><author><name sortKey="Tsutsui, T" uniqKey="Tsutsui T">T Tsutsui</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Hatano, E" uniqKey="Hatano E">E Hatano</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Kawagoe, M" uniqKey="Kawagoe M">M Kawagoe</name></author><author><name sortKey="Kajiya, S" uniqKey="Kajiya S">S Kajiya</name></author><author><name sortKey="Mizushima, K" uniqKey="Mizushima K">K Mizushima</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Thorsen, Am" uniqKey="Thorsen A">AM Thorsén</name></author><author><name sortKey="Holmqvist, Lw" uniqKey="Holmqvist L">LW Holmqvist</name></author><author><name sortKey="De Pedro Cuesta, J" uniqKey="De Pedro Cuesta J">J de Pedro-Cuesta</name></author></analytic></biblStruct><biblStruct><analytic><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">J Phys Ther Sci</journal-id><journal-id journal-id-type="iso-abbrev">J Phys Ther Sci</journal-id><journal-id journal-id-type="publisher-id">JPTS</journal-id><journal-title-group><journal-title>Journal of Physical Therapy Science</journal-title></journal-title-group><issn pub-type="ppub">0915-5287</issn><issn pub-type="epub">2187-5626</issn><publisher><publisher-name>The Society of Physical Therapy Science</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">26644671</article-id><article-id pub-id-type="pmc">4668162</article-id><article-id pub-id-type="publisher-id">jpts-2015-406</article-id><article-id pub-id-type="doi">10.1589/jpts.27.3185</article-id><article-categories><subj-group subj-group-type="heading"><subject>Original Article</subject></subj-group></article-categories><title-group><article-title>Development and evaluation of a new telerehabilitation system based on VR
technology using multisensory feedback for patients with stroke</article-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Kato</surname><given-names>Norio</given-names></name><degrees>RPT</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref rid="cor1" ref-type="corresp"><sup>*</sup></xref></contrib><contrib contrib-type="author"><name><surname>Tanaka</surname><given-names>Toshiaki</given-names></name><degrees>RPT, PhD</degrees><xref ref-type="aff" rid="aff1"><sup>1</sup></xref><xref ref-type="aff" rid="aff3"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Sugihara</surname><given-names>Syunichi</given-names></name><degrees>RPT</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref><xref ref-type="aff" rid="aff4"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Shimizu</surname><given-names>Koichi</given-names></name><degrees>PhD</degrees><xref ref-type="aff" rid="aff2"><sup>2</sup></xref></contrib><aff id="aff1"><label>1)</label> Department of Physical Therapy, Faculty of Health Science, Hokkaido University of Science, Japan</aff><aff id="aff2"><label>2)</label> Graduate School of Information Science and Technology, Hokkaido University, Japan</aff><aff id="aff3"><label>3)</label> Institute of Gerontology, The University of Tokyo, Japan</aff><aff id="aff4"><label>4)</label> Sapporo Syuyukai Hospital, Japan</aff></contrib-group><author-notes><corresp id="cor1"><label>*</label>Corresponding author. Norio Kato, Department of Physical Therapy, Faculty of Health Science,
Hokkaido University of Science: 7-15-4-1 Maeda, Teine, Sapporo, Hokkaido 006-8585,
Japan. (E-mail: <email xlink:href="kato-n@hus.ac.jp">kato-n@hus.ac.jp</email>)</corresp></author-notes><pub-date pub-type="epub"><day>30</day><month>10</month><year>2015</year></pub-date><pub-date pub-type="ppub"><month>10</month><year>2015</year></pub-date><volume>27</volume><issue>10</issue><fpage>3185</fpage><lpage>3190</lpage><history><date date-type="received"><day>18</day><month>5</month><year>2015</year></date><date date-type="accepted"><day>16</day><month>7</month><year>2015</year></date></history><permissions><copyright-statement>2015©by the Society of Physical Therapy Science. Published by IPEC
Inc.</copyright-statement><copyright-year>2015</copyright-year><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by-nc-nd/3.0/"><license-p>This is an open-access article distributed under the terms of the Creative
Commons Attribution Non-Commercial No Derivatives (by-nc-nd) License. </license-p></license></permissions><abstract><p>[Purpose] The purpose of this study was to develop a new telerehabilitation system based
on VR technology for training of paralyzed upper and lower extremities and poor balance in
patients with stroke. Moreover, the effectiveness of the system was verified by analysis
of the recovery of these patients. [Subjects] Five healthy persons and five people with
motor paralysis, caused by cerebrovascular disease, participated. [Methods] The features
of our system are as follows: (1) Our system can train upper and lower limbs and balancing
with 3D images. (2) A Kinect<sup>®</sup> is used for user posture detection. (3) A
vibrator is used for feedback to a sensory receptor in order to promote the learning
effect of motion. Upper limb and balance training were conducted in this study. [Results]
The time necessary for the upper limb and balance training tasks was shortened for the
participants with disabilities. The joint angle for the participants with disabilities
tended to equate to that of the healthy participants over time. Moreover, our system had
no side effects. [Conclusion] These points suggest that our system is effective and safe.
The user interface and assessment of the conditions of patients from a distance should be
studied in the future.</p></abstract><kwd-group><title>Key words</title><kwd>Multisensory feedback</kwd><kwd>Telerehabilitation</kwd><kwd>Virtual Reality</kwd></kwd-group></article-meta></front><body><sec sec-type="intro" id="s1"><title>INTRODUCTION</title><p>Japan, the population of which is rapidly aging, is experiencing incessant financial stress
from high medical expenses<xref rid="r1" ref-type="bibr">1</xref>, <xref rid="r2" ref-type="bibr">2</xref><sup>)</sup>. The governmental policy stance for improving this situation
has been shifting swiftly to home care. Home rehabilitation has a serious problem with
respect to maintenance of the quality of rehabilitation components because of limitation of
the rehabilitation period in Japan<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>.
Although the effectiveness of rehabilitation at home is evident<xref rid="r4" ref-type="bibr">4</xref>,<xref rid="r5" ref-type="bibr">5</xref>,<xref rid="r6" ref-type="bibr">6</xref><sup>)</sup>, the numbers of facilities and personnel are insufficient to fully
meet the needs of distant or depopulated places at present<xref rid="r3" ref-type="bibr">3</xref><sup>)</sup>. Even in the United States, the inability of handicapped elderly
people living in rural areas to receive medical services easily after leaving a hospital
that provides rehabilitation is an important issue<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>.</p><p>Telerehabilitation using a computer has been proposed as a measure to solve this issue. In
telerehabilitation, a therapist supports, evaluates, and assists handicapped persons from a
distant location using telecommunication technology<xref rid="r7" ref-type="bibr">7</xref><sup>)</sup>. Reviews of telerehabilitation efforts have revealed its
effectiveness not only in terms of clinical results but also in terms of user satisfaction
and costs<xref rid="r8" ref-type="bibr">8</xref><sup>)</sup>. Telerehabilitation systems
commonly use video or audio systems, but systems using virtual reality (VR) also exist<xref rid="r9" ref-type="bibr">9</xref><sup>)</sup>. The success of rehabilitation using VR has
been demonstrated<xref rid="r10" ref-type="bibr">10</xref>,<xref rid="r11" ref-type="bibr">11</xref>,<xref rid="r12" ref-type="bibr">12</xref>,<xref rid="r13" ref-type="bibr">13</xref>,<xref rid="r14" ref-type="bibr">14</xref>,<xref rid="r15" ref-type="bibr">15</xref><sup>)</sup>. The accomplishments of a VR-based telerehabilitation system have
also been reported<xref rid="r16" ref-type="bibr">16</xref>,<xref rid="r17" ref-type="bibr">17</xref>,<xref rid="r18" ref-type="bibr">18</xref><sup>)</sup>. Nevertheless previous
studies of telerehabilitation systems have focused on individual movements, such as finger
motion, upper limb motion, walking, and balancing, and no device yet produced can train
upper and lower limbs and balancing comprehensively.</p><p>Visual and auditory approaches are used mainly as feedback to sensory receptors that are
effective in the promotion of learning of motion. Studies of VR-based visual feedback mostly
adopt a 2D display. A 2D image provides a feeling of depth with perspective and shadow
methods, but it lacks information that can be detected or conveyed by binocular parallax,
whereas a 3D image can present such information, so it allows spatial perception closer to
nature<xref rid="r19" ref-type="bibr">19</xref><sup>)</sup>.</p><p>Aside from visual or auditory feedback, some systems adopt force feedback, which employs
haptic or exoskeleton devices. However, issues of cost, handling, and safety remain with
force feedback because of its specifications<xref rid="r20" ref-type="bibr">20</xref><sup>)</sup>. The effectiveness of feedback for deep sensation using vibratory
stimulation has been shown as a sensory feedback system<xref rid="r21" ref-type="bibr">21</xref>, <xref rid="r22" ref-type="bibr">22</xref><sup>)</sup>. Nevertheless, no
existing report in the literature describes a study of a telerehabilitation system that uses
vibratory stimulation for feedback. Because a telerehabilitation system can use a vibrator
such as that commonly built into mobile phones or smart phones, it can be regarded as an
inexpensive and safe feedback device for a distant operation.</p><p>The purpose of this study was to develop a new telerehabilitation system based on VR
technology using multisensory feedback for training of paralyzed upper and lower extremities
and poor balance in patients with stroke. Moreover, the effectiveness of the system was
verified by analysis of recovery of the patients.</p></sec><sec sec-type="methods" id="s2"><title>SUBJECTS AND METHODS</title><sec><title>Subjects</title><p>Healthy people and people with disabilities using the present system as a stand-alone
system were compared, and the changes resulting from using the system continuously were
analyzed in people with disabilities to verify system feasibility. The performance of the
system was also examined when it was operated from a distant location.</p><p>The participants in this study comprised five healthy persons with no upper limb disorder
and five people with disabilities (<xref rid="tbl_001" ref-type="table">Tables 1</xref>and<xref rid="tbl_002" ref-type="table"> 2</xref><table-wrap id="tbl_001" orientation="portrait" position="float"><label>Table 1.</label><caption><title>Healthy subject data</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">Subject</th><th align="center" rowspan="1" colspan="1">Gender</th><th align="center" rowspan="1" colspan="1">Age (yrs)</th><th align="center" rowspan="1" colspan="1">Task</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">A</td><td align="center" rowspan="1" colspan="1">Male</td><td align="center" rowspan="1" colspan="1">26</td><td align="left" rowspan="1" colspan="1">Reaching while sitting</td></tr><tr><td align="left" rowspan="1" colspan="1">B</td><td align="center" rowspan="1" colspan="1">Female</td><td align="center" rowspan="1" colspan="1">26</td><td align="left" rowspan="1" colspan="1">Balance training while standing</td></tr><tr><td align="left" rowspan="1" colspan="1">C</td><td align="center" rowspan="1" colspan="1">Female</td><td align="center" rowspan="1" colspan="1">28</td><td align="left" rowspan="1" colspan="1">Balance training while standing</td></tr><tr><td align="left" rowspan="1" colspan="1">D</td><td align="center" rowspan="1" colspan="1">Female</td><td align="center" rowspan="1" colspan="1">29</td><td align="left" rowspan="1" colspan="1">Balance training while standing</td></tr><tr><td align="left" rowspan="1" colspan="1">E</td><td align="center" rowspan="1" colspan="1">Female</td><td align="center" rowspan="1" colspan="1">24</td><td align="left" rowspan="1" colspan="1">Balance training while standing</td></tr></tbody></table></table-wrap>). One healthy participant and two participants with stroke received upper
limb training in a sitting position with the stand-alone system. Four healthy participants
and one participant with stroke received balance training in a standing position with the
stand-alone system. One participant with stroke received upper limb training in a sitting
position with the system controlled from a distant location. Among participants with
disabilities, those who received upper limb training were administered a Simple Test for
Evaluating Hand Function (STEF) and the Functional Independence Measure (FIM). Those who
received balance training were administered the Functional Balance Scale (FBS) and FIM.
Those who received rehabilitation with the system controlled from a distant location were
evaluated for Brunnstrom Stage (<xref rid="tbl_002" ref-type="table">Table
2</xref><table-wrap id="tbl_002" orientation="portrait" position="float"><label>Table 2.</label><caption><title>Patient data</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="center" rowspan="1" colspan="1">Subject</th><th align="center" valign="middle" rowspan="1" colspan="1">Gender</th><th align="center" valign="middle" rowspan="1" colspan="1">Age<break></break>(yrs)</th><th align="center" valign="middle" rowspan="1" colspan="1">Diagnosis</th><th align="center" valign="middle" rowspan="1" colspan="1">Affected<break></break>Side</th><th align="center" valign="middle" rowspan="1" colspan="1">Period between onset<break></break>and VR training (days)</th><th align="center" valign="middle" rowspan="1" colspan="1">Task</th><th align="center" valign="middle" rowspan="1" colspan="1">Clinical assessment</th></tr></thead><tbody><tr><td align="center" rowspan="1" colspan="1">F</td><td align="center" rowspan="1" colspan="1">Female</td><td align="center" rowspan="1" colspan="1">50</td><td align="center" rowspan="1" colspan="1">Cerebral infarction</td><td align="center" rowspan="1" colspan="1">Right</td><td align="center" rowspan="1" colspan="1">17</td><td align="center" rowspan="1" colspan="1">Reaching while sitting</td><td align="center" rowspan="1" colspan="1">STEF 32 (100) / FIM 106 (126)</td></tr><tr><td align="center" rowspan="1" colspan="1">G</td><td align="center" rowspan="1" colspan="1">Male</td><td align="center" rowspan="1" colspan="1">83</td><td align="center" rowspan="1" colspan="1">Cerebral infarction</td><td align="center" rowspan="1" colspan="1">Right</td><td align="center" rowspan="1" colspan="1">32</td><td align="center" rowspan="1" colspan="1">Reaching while sitting</td><td align="center" rowspan="1" colspan="1">STEF 83 (100) / FIM 112 (112)</td></tr><tr><td align="center" rowspan="1" colspan="1">H</td><td align="center" rowspan="1" colspan="1">Female</td><td align="center" rowspan="1" colspan="1">61</td><td align="center" rowspan="1" colspan="1">Brain stem infarction</td><td align="center" rowspan="1" colspan="1">Left</td><td align="center" rowspan="1" colspan="1">712</td><td align="center" rowspan="1" colspan="1">Balance training while standing</td><td align="center" rowspan="1" colspan="1">FBS 41 (56) / FIM 100 (126)</td></tr><tr><td align="center" rowspan="1" colspan="1">I</td><td align="center" rowspan="1" colspan="1">Male</td><td align="center" rowspan="1" colspan="1">56</td><td align="center" rowspan="1" colspan="1">Cerebral hemorrhage</td><td align="center" rowspan="1" colspan="1">Right</td><td align="center" rowspan="1" colspan="1">506</td><td align="center" rowspan="1" colspan="1">Balance training while standing</td><td align="center" rowspan="1" colspan="1">FBS 46 (56) / FIM 112 (126)</td></tr><tr><td align="center" rowspan="1" colspan="1">J</td><td align="center" rowspan="1" colspan="1">Male</td><td align="center" rowspan="1" colspan="1">67</td><td align="center" rowspan="1" colspan="1">Cerebral infarction</td><td align="center" rowspan="1" colspan="1">Right</td><td align="center" rowspan="1" colspan="1">2230</td><td align="center" rowspan="1" colspan="1">Reaching while sitting on telerehabilitation</td><td align="center" rowspan="1" colspan="1">Br Stage U/E III</td></tr></tbody></table></table-wrap>). This research was part of a study that obtained approval from the ethics
committees of the University of Hokkaido, the University of Tokyo, and Sapporo Shuyukai
Hospital. The subjects received a thorough explanation about the study contents and
methods both orally and in writing, and their written consent to participation was
received.</p></sec><sec><title>Methods</title><p>A block diagram of the telerehabilitation system prototype is presented in <xref ref-type="fig" rid="fig_001">Fig. 1</xref><fig orientation="portrait" fig-type="figure" id="fig_001" position="float"><label>Fig. 1.</label><caption><p>Block diagram of the telerehabilitation system</p></caption><graphic xlink:href="jpts-27-3185-g001"></graphic></fig>. Components of the rehabilitation program prepared using this system were presented
using 3D image. Graphical data generated by the system were converted into stereoscopic 3D
data through the Tridef<sup>®</sup> 3D middleware (Dynamic Digital Depth USA Inc.). A
polarized display (Mitsubishi RDT234WX-3D) was used for the system, and the users wore
polarized glasses so that they could see 3D images. Although polarized displays have the
inherent disadvantage of half the resolution compared with normal displays, they have the
advantages of being flicker-free and being able to present image information
simultaneously to both eyes. In addition, polarized glasses are light enough that they can
be worn comfortably. Even clip-on type devices can be furnished for fitting over
glasses.</p><p>A Kinect<sup>®</sup> (Microsoft Corp.), which facilitates unconstrained measurement of
body coordinates, was used for user posture detection. The Kinect<sup>®</sup> measures the
distance from its camera to the body surface using infrared light. It then estimates the
positions and attitudes of body segments. Because the Kinect<sup>®</sup> requires no
adhesive markers, which are necessary for ordinary motion analysis devices, it reduces the
load borne by the user.</p><p>A vibrator (Kyowa Electronic Instruments Co., Ltd.) was used to provide feedback to a
sensory receptor. It was fixed to a Velcro<sup>®</sup> band. The users performed the
component of the rehabilitation program with the band fixed to the hand.</p><p>Skype<sup>®</sup> (Microsoft Corp.), which permits users to make video calls at no
charge, was used for conversations with video and audio between patients in distant
locations and a therapist. In addition, the PubNub<sup>®</sup> Real-Time Network, a
communication service provided by PubNub, Inc., was used for transmission and reception of
commands or real-time data communication of states so that a therapist could monitor the
components of the rehabilitation program and control the system from a distant location.
Furthermore, the Dropbox<sup>TM</sup> file-sharing service was used for collection of the
raw position data necessary for detailed off-line data analysis. This system can be put in
practical use as a stand-alone system or operated from a distant location.</p><p>For upper limb and balance training, the present system displayed virtual objects as
targets. The participant was required to extend their upper limbs to touch them. The
position of the targets in space and the movements of the upper limbs of the participant
were shown on the 3D display using computer graphics (<xref ref-type="fig" rid="fig_002">Fig. 2</xref><fig orientation="portrait" fig-type="figure" id="fig_002" position="float"><label>Fig. 2.</label><caption><p>VR rehabilitation game scene</p><p>The 3D display presents the virtual targets and movement of the upper limbs of the
participant using CG.</p></caption><graphic xlink:href="jpts-27-3185-g002"></graphic></fig>). When a reaching motion was made that touched a target, a tactile feeling was fed
back by the vibration device attached to the hand. The targets were located on coordinate
axes centered on the acromion, and their positions were determined according to upper limb
length.</p><p>The upper limb training in a sitting position comprised an upward reaching motion, a
lateral reaching motion, and a forward reaching motion. For the upward reaching motion,
targets were positioned at a depth equivalent to 85% of the upper limb length and at
flexion angles of the shoulder joint of 45°, 90°, and 135°, respectively. For the lateral
reaching motion, one target was positioned on 85% of upper limb length at the 90 degrees
shoulder flexion and two targets were also placed at the range of between the 45 degrees
abduction and the 45 degrees adduction of the shoulder joint. For the forward reaching
motion, three targets were aligned with an acromial line. The farthest target was set at a
distance greater than the upper limb length. Upper limb training was initiated with all
targets present. The participant performed 10 trials for each task per day in addition to
ordinary rehabilitation. Participants with disabilities executed the training continually
for 20 days.</p><p>The targets were positioned in two hemispheres centered on the unaffected acromion in the
balance training in a standing position. The radii of the hemispheres were set to 60% and
85% of the upper limb length. Nine targets were placed in each hemisphere (a total of 18
targets). Targets were displayed randomly; a new target appeared when target was touched.
The healthy participants and participants with disabilities performed three trials of
balance training each day.</p><p>Regarding telerehabilitation, the upper limb training task was conducted in a sitting
position by connecting the system in the participant’s home with a hospital via the
Internet using mobile devices (E-mobile; LTE) (<xref ref-type="fig" rid="fig_003">Fig.
3</xref><fig orientation="portrait" fig-type="figure" id="fig_003" position="float"><label>Fig. 3.</label><caption><p>Test of operation of the telerehabilitation system from a distant location</p></caption><graphic xlink:href="jpts-27-3185-g003"></graphic></fig>).</p><p>The time necessary for task execution and the 3D coordinate data of each joint acquired
from the measured data were used for analyses. Analyzed items included the average time
necessary and joint angle for the upper limb training task, the average time required for
the balance training task, and the average time required and coordinate changes in the
telerehabilitation task. The measured joint angles were flexion of the shoulder joint,
horizontal flexion of the shoulder joint, flexion of the elbow joint, and dorsal flexion
of the wrist joint. Data of six trials, except for the first two and last two trials out
of ten trials, were extracted for each upper limb training task for comparison between
healthy participants and participants with disabilities. Moreover, the average times
required in the first and last trials and the average of each joint angle were compared
for the participants with disabilities. The average time necessary for three trials of the
balance training task was calculated. Then the healthy participants and participants with
disabilities were compared. The performance of the system when operated from a distant
location was examined according to the circumstances of communication and real-time
monitoring and the conditions of data transmission and reception.</p></sec></sec><sec sec-type="results" id="s3"><title>RESULTS</title><p><xref rid="tbl_003" ref-type="table">Table 3</xref><table-wrap id="tbl_003" orientation="portrait" position="float"><label>Table 3.</label><caption><title>Average time necessary for each upper limb training task in a sitting
position</title></caption><table frame="hsides" rules="groups"><thead><tr><th colspan="2" align="left" rowspan="1"></th><th align="center" rowspan="1" colspan="1">Upward reaching</th><th align="center" rowspan="1" colspan="1">Forward reaching</th><th align="center" rowspan="1" colspan="1">Lateral reaching</th></tr></thead><tbody><tr><td align="left" colspan="2" rowspan="1">Control</td><td align="center" rowspan="1" colspan="1">2.9</td><td align="center" rowspan="1" colspan="1">2.4</td><td align="center" rowspan="1" colspan="1">4.0</td></tr><tr><td align="left" rowspan="2" colspan="1">Patient</td><td align="left" rowspan="1" colspan="1">First session</td><td align="center" rowspan="1" colspan="1">7.2±0.4</td><td align="center" rowspan="1" colspan="1">3.7±0.6</td><td align="center" rowspan="1" colspan="1">6.8±2.0</td></tr><tr><td align="left" rowspan="1" colspan="1">Last session</td><td align="center" rowspan="1" colspan="1">3.5±0.65</td><td align="center" rowspan="1" colspan="1">2.4±0.9</td><td align="center" rowspan="1" colspan="1">3.7±0.96</td></tr></tbody></table><table-wrap-foot><p> (sec)</p></table-wrap-foot></table-wrap> presents the average time necessary for each upper limb training task for the
healthy participant and participants with disabilities. Patients required more time than the
healthy participants to execute all tasks in the first trial, but the necessary time shorter
in the last trial compared with the first trial for the participants with disabilities.</p><p><xref rid="tbl_004" ref-type="table">Table 4</xref><table-wrap id="tbl_004" orientation="portrait" position="float"><label>Table 4.</label><caption><title>Changes in shoulder and elbow joint angles during each reaching task in a sitting
position</title></caption><graphic xlink:href="jpts-27-3185-t004"></graphic></table-wrap>shows the joint angle of each participant during reaching tasks in a sitting
position. In the upward reaching task, the flexion of the shoulder joint was set to be 135°.
The flexion of the shoulder joint of the healthy participant was close to the expected value
of 135°. The flexion of the shoulder and elbow joint of disabled participant F approached
that of the healthy participant in the last trial compared with the first trial. The flexion
of the shoulder joint of disabled participant G did not change, but the flexion of his elbow
joint eventually approached that of the healthy participant.</p><p>In the forward reaching task, the subjects were asked to reach toward the farthest target
set in front of them. The angle for the healthy participant was close to the anticipated
value, but the flexion of the shoulder joint was smaller and that of the elbow joint was
larger for the participants with disabilities compared with those for the healthy
participant. Regarding secular changes in the participants with disabilities, flexion of the
shoulder joint increased and the flexion of the elbow joint decreased in the last trial
compared with the first trial.</p><p>When the horizontal flexion of the shoulder joint and the flexion of the elbow joint are
setting to be 45° and 0°, respectively, in the lateral reach motion task. The flexion of the
elbow joint was greater for the participants with disabilities than for the healthy
participant. The flexion of the shoulder joint for disabled participant G increased finally.
The flexion of the elbow joint for participants with disabilities F and G decline at the
last trial to approach that of the healthy participant.</p><p><xref rid="tbl_005" ref-type="table">Table 5</xref><table-wrap id="tbl_005" orientation="portrait" position="float"><label>Table 5.</label><caption><title>Average performance time in the balance task</title></caption><table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="center" rowspan="1" colspan="1">1st Trial</th><th align="center" rowspan="1" colspan="1">2nd Trial</th><th align="center" rowspan="1" colspan="1">3rd Trial</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Control</td><td align="center" rowspan="1" colspan="1">58.0±5.2</td><td align="center" rowspan="1" colspan="1">43.1±3.3</td><td align="center" rowspan="1" colspan="1">42.8±3.4</td></tr><tr><td align="left" rowspan="1" colspan="1">Patient</td><td align="center" rowspan="1" colspan="1">377.0±190.3</td><td align="center" rowspan="1" colspan="1">114.8±23.3</td><td align="center" rowspan="1" colspan="1">104.1±27.7</td></tr></tbody></table><table-wrap-foot><p>(sec)</p></table-wrap-foot></table-wrap> presents the results of comparison of the average time required for the
healthy participants and participant with disabilities in the balance task. The healthy
participants were able to complete the task in an almost constant amount of time beginning
at the start. Although the participant with disabilities required more time in the first
trial, the time was shorter after the second trial. Neither healthy participants nor
participants with disabilities exhibited a severe degree of loss of balance during
performance of the task.</p><p>Network connectivity was established promptly for video calls and file transfers in
operation of the telerehabilitation system. No delay in data transfer occurred that
interfered with assessment or control of the situation. The data measured on the
participant’s side were transmitted to the hospital in real time. The hospital was then able
to assess the motion of the participant. Although some attitude data were lost in
communication, a complete data file was transmitted promptly via the Dropbox<sup>TM</sup>file-sharing service to the hospital within less than a minute completion of
measurements.</p></sec><sec sec-type="discussion" id="s4"><title>DISCUSSION</title><p>In this study, a VR-based telerehabilitation system was developed. This system can be
utilized to enable elderly and disabled people to receive the same quality of rehabilitation
at home as they would in home-visit and day-care rehabilitation. The effectiveness and the
feasibility of the system were examined for stroke patients.</p><p>Issues that must be examined when constructing a rehabilitation system that uses VR include
usability, safety, and cost, as well as effectiveness. Because the users assumed in this
study were handicapped elderly people, we determined that the system must be low-cost,
user-friendly, and safe. Moreover, because operation from a distant location presumably
involves a hospital, which would have robust network security, priority was assigned to
ensuring that a stable connection could be made with the system in the home of a patient
without altering any settings inside the hospital.</p><p>This system used a Kinect<sup>®</sup>, which is made by Microsoft Corp., for motion
measurement. The Kinect<sup>®</sup> can perform motion capture to ascertain the posture of
each joint without special calibration or markers. Therefore, the system can be operated
without difficulty by just installing a Kinect<sup>®</sup> during system setup. Furthermore,
the Kinect<sup>®</sup> is advantageous in that it is available at a low price compared with
other commercial operation-analysis devices. Studies of VR rehabilitation system using the
Kinect<sup>®</sup> have demonstrated its effectiveness<xref rid="r23" ref-type="bibr">23</xref>, <xref rid="r24" ref-type="bibr">24</xref><sup>)</sup>. However, the
Kinect<sup>®</sup> is occasionally unable to recognize a joint marker because of complex
or fast joint movement, so a detailed analysis might require the correction of error
data.</p><p>A therapist operated the computer because the Kinect<sup>®</sup> recognize user’s movement
by maintaining the distance (approximately 1.8 m) between Kinect<sup>®</sup> and the user.
Because the system currently requires an operator to control the software with a mouse or
keyboard, conducting training in a location distant from the computer is difficult. The user
interface must be improved in the future by making it possible to control the software
without a mouse or keyboard by using the motion of a subject’s unaffected side taking
advantage of the features of the Kinect<sup>®</sup>.</p><p>Information related to depth was given to the participants as visual information using a
commercially available 3D display, with the aim of providing a training environment in an
environment closer to reality. The actual users’ opinion demonstrated that this assisted
them in comprehending the spatial relation between their hand and computer-generated
targets. The effect of virtual reality sickness should be examined with respect to 3D
graphics<xref rid="r25" ref-type="bibr">25</xref><sup>)</sup>. No symptom of virtual
reality sickness was observed either in the present rehabilitation session or in a pilot
survey performed in advance. Moreover, because a polarized display was used for the system,
there were no complaints regarding flicker, trouble seeing images, or asthenopia. These
points suggest that this system is a physiologically safe.</p><p>When a user reached to a target on the display, a vibrator stimulated a touch sensation of
the user as a sensory feedback. The vibrator was fixed to a Velcro band so that it could be
worn without difficulty. Because the vibrator used in this study is small and lightweight,
it is suitable for mobile phones and smart phones. It is also regarded as safe. Moreover,
many of the participants in this study reported that this method assisted them in
comprehending when a target was touched.</p><p>Skype<sup>®</sup>, PubNub<sup>®</sup>, and Dropbox<sup>TM</sup>, which were used in this
study to provide a robust network environment, present benefits such as the ability to
easily pass through a firewall, no need for a special server, and simple installation in a
patient’s home or a hospital. Although some data were lost in real-time data transfer, it
presented no great difficulty for monitoring. In addition, because raw data are useful for
off-line analysis, satisfactorily detailed evaluation was assured.</p><p>Upper limb and balance training were conducted in this study to examine the components of a
rehabilitation program. The time necessary for the upper limb training task decreased with
time in the participants with disabilities. The joint angle for the participants with
disabilities tended to become equivalent to that of the healthy participants over time.
Consequently, kinematic data also supported the system effectiveness. The results
demonstrating that the VR system improved motor functions show good agreement with the
findings of previous research of VR use in stroke patients<xref rid="r10" ref-type="bibr">10</xref>,<xref rid="r11" ref-type="bibr">11</xref>,<xref rid="r12" ref-type="bibr">12</xref>,<xref rid="r13" ref-type="bibr">13</xref>,<xref rid="r14" ref-type="bibr">14</xref>,<xref rid="r15" ref-type="bibr">15</xref>,<xref rid="r16" ref-type="bibr">16</xref>,<xref rid="r17" ref-type="bibr">17</xref>,<xref rid="r18" ref-type="bibr">18</xref><sup>)</sup>. Upper limb motor function presumably improved because the affected
side was exercised intensively using a VR game that was similar to constraint-induced
therapy<xref rid="r26" ref-type="bibr">26</xref><sup>)</sup>. This system fed back a
tactile sensation to a target contact using a vibrator. Feedback to a sensory receptor
promotes effective relearning of motion<xref rid="r27" ref-type="bibr">27</xref><sup>)</sup>. It is therefore also regarded as having encouraged positive upper
limb motion engendering the recovery of motor functions in the present study. The balance
training task required a long time for the participants with disabilities in the first
trial. However, the task could be completed in a shorter time after the second trial. The
reasons for this include that the contents of the tasks performed in this study were easy to
understand for participants with disabilities. Training will be continued, and the effects
of balance training in a standing position will be observed in future studies.</p><p>In the present study, it was found that the participants with disabilities touched targets
with smaller angular movements in each joint than anticipated in the upper limb training
task. This showed that the subjects might be compensating for paralysis by moving the trunk.
The compensatory action is presumed to be an inhibitor in the process of recovery from
paralysis. Therefore, appropriate instruction for accurate movement of the trunk and upper
extremities must be given during telerehabilitation.</p><p>Accordingly, we expect to improve this system so that a therapist can give appropriate
instruction in real time through a display when operating the system from a distant location
and so that the state of the trunk and lower limb of a user will be displayed on a screen
using computer graphics. The present system adopted a simple task of touching a target so
that elderly people or people with disabilities could understand it easily. However, the
system has a few problems: operation of the PC to use the system is difficult, and the
system cannot be applied to versatile patients. In the near future, the components of the
rehabilitation system and the usability of the system will be enhanced so that the user’s
motivation can be sustained.</p></sec></body><back><ack><p>This work was partly supported by the Strategic Information and Communications R&D
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