SCRIPT: Tele-robotics at Home

Functional Architecture and Clinical Application

G. B. Prange

, H. J. Hermens

, J. Schäfer

, N. Nasr

, G. Mountain

, A. H. A. Stienen

and

F. Amirabdollahian

Roessingh Research and Development, Roessinghsbleekweg 33b, Enschede, The Netherlands

User Interface Design, Ludwigsburg, Germany

School of Health and Related Research, University of Sheffield, Sheffield, U.K.

Department of Biomechanical Engineering, University of Twente, Enschede, The Netherlands

Adaptive Systems Research Group, The University of Hertfordshire, Hertfordshire, U.K.

Keywords: Remote Treatment, Remote Monitoring, Decision Support, Rehabilitation Robotics, Upper Extremity,

Hand, Stroke.

Abstract: After the event of a stroke, patients have at least 12 months during which their brains are highly susceptible

to the benefits of neuro-rehabilitation treatments. On the other hand, due to the high costs of clinical neuro-

rehabilitation, post-stroke treatments are limited in all countries to only a few weeks after the stroke event.

Hence, any system aimed at prolonging neuro-rehabilitation at patients’ homes, and with low-cost

treatments, addresses a major issue in the current health management systems. Recent developments have

revealed a great potential for robotic devices delivering repetitive training to improve arm function after

stroke, thus facilitating a high intensity and a large number of repetitive training. The SCRIPT project aims

to develop robotic technologies for the home as it would enable self-administration of more intense and

more frequent exercises, by enabling hand and wrist exercise that have great potential for contribution to

personal independence. Remote management and support of the patient is incorporated through a

communication platform that supports the remote adjustment of the therapy program. In this way, the

patient can exercise at home, while the exercise is remotely supervised without increasing therapist time,

while reducing the frequency of hospital or clinics visits.

1 INTRODUCTION

Functional recovery from stroke demands a long

period of physical and often cognitive rehabilitation.

Research into motor relearning and cortical

reorganization after stroke has provided a

neurophysiological basis for key aspects that

stimulate restoration of arm function (Schaechter,

2004; Krakauer, 2005). These key aspects include

high training intensity, active initiation and

execution of movements, and application of

functional exercises. Technological innovations

provided an opportunity to design interventions that

take many key aspects for stimulation of motor

relearning into account, of which rehabilitation

robotics is a well-known example. With such a

device, the required amount of movement support

can be provided, thereby allowing active practice

when this is not possible otherwise. This increases

the potential to train intensively, with the patient’s

active contribution to functional exercises.

The application of rehabilitation robotics has

been shown to be effective for the hemiparetic arm

(Prange, 2006; Kwakkel 2008; Mehrholz 2008).

However, transfer of robotic training effects to

activities in daily life is limited, as is observed for

most interventions in stroke rehabilitation, including

conventional therapy (Wagenaar, 1991).

Contemporary robot-aided therapy focuses mainly

on the proximal arm, and results in improvements in

the proximal arm only, without generalization to the

wrist and hand (Prange, 2006). This is while wrist

and hand play a major role in a person’s functional

independence. In order to maximize independent use

of the upper extremity in daily life, it is important to

include functional practice of the wrist and hand.

Amirabdollahian F., Schäfer J., Stienen A., Mountain G., Nasr N., Hermens H. and Prange G. (2012).

SCRIPT: Tele-robotics at HomeFunctional Architecture and Clinical Application.

In Proceedings of the Sixth International Symposium on e-Health Services and Technologies and the Third International Conference on Green IT

Solutions, pages 58-63

DOI: 10.5220/0004474100580063

 SciTePress

In the setting of the rehabilitation centre,

intensive training of arm and hand is supervised by

highly skilled professionals. However, the time that

can be spent on training in such intramural settings

is limited. Due to the high costs of clinical neuro-

rehabilitation, post-stroke treatments are limited to

only a few weeks with limited treatment resources

after the stroke event in many countries. Hence, any

system aimed at prolonging neuro-rehabilitation out

of the clinics, i.e. at patients’ homes and with low-

cost treatments, addresses a major issue in the

current health management systems.

While there is growing evidence that

rehabilitation technologies are beneficial to the

patients’ recovery of functional and motor outcome

(i.e., Prange, 2006; Kwakkel, 2008; Mehrholz,

2008), the uptake of these technologies has been

slow. This is thought to be caused by the lack of

stronger clinical evidence for usefulness, adherence

of carers/clinicians, lack of platforms designed along

clinically useful practice, limitations on post-

discharge practice frequency based on service or

motivation limits, absence of platform flexibility,

cost and weakness in addressing interoperability

issues among healthcare systems in the EU.

The SCRIPT (Supervised Care & Rehabilitation

Involving Personal Tele-robotics) project aims to

address several of these important issues: using

robotic technologies at home as it would enable self-

administration of more intense and more frequent

exercise, by enabling hand and wrist exercise that

have great potential for contribution to personal

independence. This is the concept of

telerehabilitation considered by many as the future

(Hermens, 2008).

However, telerehabilitation is still in its infancy.

In a recent review (Johansson, 2010), only very

limited amount of ICT-supported treatments were

available. Of the nine studies included in the review,

four studies focused on a teleconsultation service for

stroke patients. With respect to technology-

supported telerehabilitation, only three studies were

found: two utilizing the same virtual reality-based

system that provided motor tasks to the patients and

only one study, originating from the European HCad

and HelloDoc projects, utilising a sensitized exercise

table with synchronous video teleconsultation to

enable supervised arm/hand exercising at home. One

of the aspects reflecting the present immaturity of

telerehabilitation concerns the unavailability of a

decision support system. In order to make large scale

clinical application possible and to make such

systems cost-effective, it is required that a decision

support system is in place that supports clinical

decision making by doing a smart analysis of the

physiological and biomechanical data in its proper

context.

The aim of the present paper is to present the

functional architecture and future clinical directions

of the SCRIPT tele-robotics platform, which is

targeted at improving arm function after stroke by

enabling home-based, robot-supported arm and hand

training. Since designing such an interactive system

often doesn’t meet the criteria needed for a usable

system, user-centred design methods are applied

from the start of the development of the interactive

system (Abras, 2004). By applying four steps:

identifying needs and user requirements, developing

alternative designs, building interactive versions,

evaluating the different options (Sharp, 2006), the

end user is allowed to shape the design of the

SCRIPT tele-robotics system.

2 FUNCTIONAL

ARCHITECTURE

The SCRIPT project will create a system,

progressing beyond the present state of art, in a

number of aspects. The goal of developing a home

usable device for chronic stroke patient poses many

challenges. At its heart, safety during robotic

interaction is an elemental consideration. Passive-

actuation is chosen due to its superior and inherent

safety and importantly, its implications on reducing

cost. In addition, there is evidence that passive-

actuation can be as beneficial as active actuation

(Amirabdollahian, 2007). Therapeutic scenarios

detailed in user-driven design framework are to be

implemented in the prototype devices as meaningful

human-robot interaction. The idea is to identify and

tune, based on person’s capabilities, the percent

contribution required by the robot during human-

robot interaction. Figure 1 shows the functional

blocks of the complete system.

The project considers two different user

interfaces for the interaction with the system: one for

the patient and one for the clinician. The user

interface for patients provides motivational and

engaging content with an easy to use front end

(which supports multiple languages for interaction).

Patients’ therapy is facilitated using a series of

therapeutic games. In addition the system will allow

on-line support, assessment of instructional videos

and user friendly and motivating monitoring

functions of the progress made.

SCRIPT: Tele-robotics at Home - Functional Architecture and Clinical Application

Figure 1: Functional architecture of SCRIPT system.

The user interface used by the clinicians will

include different features, required to remotely

manage or observe, and in the case of active device

provides a chance for remote tuning of the device.

Clinical users require to observe progress in a range

of different aspects but not necessarily using the

same progress indicators as seen by the patients.

Automated data collection will be supported on

the outcome variables of the exercises, subjective

data from questionnaires and diaries and

intermediate process variables for treatment. These

functions will be performed in a secure dependable

way, taking care that privacy and data integrity are

guaranteed. The training equipment generates large

quantities of data that cannot be monitored

continuously by the health care professional or by

the patient. A set of clinically relevant features will

be determined continuously and made available to

both the clinician and the patient. These will be

combined with contextual information and

reasoning, to result in a set of recommendations and

a comprehensive presentation of the most relevant

data.

2.1 Building Blocks

Considering the functional architecture of the

SCRIPT tele-robotics system, figure 2 displays its

building blocks. A short description of its main

components is presented below.

2.1.1 Robotic Device

The device consists of a commercially available

weight support mechanism (Saebo Mobile Arm

Support) on top of which a wrist and hand therapy

device is mounted. The device can be used for all

activities of daily living. The wrist and hand

component includes manipulation of wrist

flexion/extension and different grasping movements

with the thumb, fingers and palm of the hand.

Assist‐as‐needed is provided through passive and

active actuators, respectively springs and electric

motors. Combining passive with active actuators

provides an optimal balance between power output,

control opportunities and device weight. The

actuators and mounted sensors also allow for

interactive feedback and haptic object manipulation.

2.1.2 Adaptive Therapeutic

Human-robot-interaction

Therapeutic scenarios detailed in user-driven design

framework are to be implemented in the prototype

devices as meaningful human-robot interaction. To

do this, this block focuses on position lag and energy

transfer direction (from human to robot or vice

versa) towards benchmarking/guiding the interaction

between the person and the robot prototype. The

idea is to identify and tune, based on person’s

capabilities, the percent contribution required by the

robot during human-robot interaction. The under-

lying interaction is compared to established models

EHST/ICGREEN 2012

Figure 2: Building blocks of SCRIPT system.

such as minimum jerk (Hogan, 1984) providing

opportunities for new benchmarks for grasping.

Using these benchmarks, it is possible to adjust the

robot’s assistive or resistive forces automatically

providing an adaptive and therapeutic human-robot

interface.

2.1.3 Remote Interaction and Decision

Support

The sensor signals from the robotic device,

reflecting the human interaction during the game,

are sampled, processed and normalised to enable

real-time comparison with the pre-determined

therapeutic goals. A subset of the central database is

loaded in the local database at start-up, containing

patient history and specific game settings. During

the use of the SCRIPT system, new data is added to

the local database continuously and synchronised

with the main remote database. The data is also used

to generate reports to be included in the patient

health record.

A model will be developed that is able to

automatically process the sensor data in different

consecutive steps to obtain a set of dynamically

changing features. These will be combined with

contextual information and reasoning will result in a

set of recommendations and a comprehensive

presentation of the most relevant data.

2.1.4 User Interfaces

Portals will be developed that enable a

comprehensive and motivating presentation of the

data. This requires a very different presentation for

the patient and the clinician that coaches. Whereas

clinicians are used to interpreting graphs, this is

often not the case for the patient, so starting from the

user requirements (from the patient perspective)

special GUI’s have to be researched and developed.

In this way the loop will be closed at three

different levels, enabling adequate and efficient

monitoring and coaching: the patient gets direct

feedback during the exercise from the robotic

device, he is able to monitor his improvements via

the portal and he receives coaching from his care

professional, who is also able to monitor the

progress via the portal.

3 CLINICAL APPLICATION

3.1 Clinical Evaluation

The clinical study design applied in this project

involves two different types of evaluation,

underpinning technology development: Formative

Evaluation (FE) or user-engagement in design and

SCRIPT: Tele-robotics at Home - Functional Architecture and Clinical Application

system development and Summative Evaluation

(SE) or the evaluation of the finished (functioning)

product.

In Formative Evaluations, users of a technology

system can provide useful information during the

process of system development (Monk, 1993). Initial

engagement with the potential users of the system is

needed to create a clear understanding of the target

users and the context in which the users intend to

use the system. In the process of specification the

system is designed, developed and tested through an

iterative cycle in which the developers are able to

find out how easy/difficult the system is to use by

users and to help them understand what problems

the system poses and how these problems could be

improved. The outcome of evaluation is considered

and alterations made to the design for the next

iteration of the prototype. This set-up of formative

evaluations allows use and acceptance of the

developed systems to be evaluated in practical

situations.

The summative evaluation allows for assessing

whether use of self-administered tele-robotic devices

can influence improvement of arm and hand

function captured during home therapy. This is made

possible by recruiting volunteering patients at the

chronic stage of stroke recovery, and allowing them

to use the system at their comfort for a six-week

period. Patients are assessed clinically; prior to, after

and at two-month post-intervention using established

and validated clinical outcomes. This investigation

also allows validating usefulness due to involvement

of three user-evaluation centres (University of

Sheffield in the United Kingdom, San Raffaele

S.p.A. in Italy, Roessingh Research and

Development in the Netherlands) for each stage of

the evaluation. Analysis of the clinical outcomes, as

well as amount of use, intensity of training, usability

and user acceptance, allows for a comprehensive

analysis of the factors contributing to improved arm

and hand function and compliance to home-based

treatment.

At present, the SCRIPT project is in its initial

stages. The stage of user and system requirements

identification during FE is ongoing. In the next

stages of the project, these requirements will be

implemented during design of the SCRIPT system,

after which SE will be carried out.

3.2 Future Clinical Directions

The SCRIPT tele-robotic platform ultimately

enables application of robotic technologies at home.

This allows self-administration of more intense and

more frequent exercise, by enabling hand and wrist

exercise that have great potential for contribution to

personal independence. This is done by providing an

educational, motivational and engaging interaction,

which makes a therapy session more enjoyable while

having the capabilities to provide feedback to

patients (in support of relearning) and to the

healthcare professionals. To enable this, remote

management and support of the patient is

implemented, through a communication platform

that supports the remote adjustment of the therapy

program, thus reducing the frequency of hospital or

home visits. This is facilitated by incorporating

clinical workflows into user interfaces used by

patients and clinicians, while maintaining a

customisable and easy to operate front-end for users.

In this way, the patient can exercise at home, while

the exercise is remotely supervised.

4 CONCLUSIONS

Based on a multidisciplinary approach, the SCRIPT

tele-robotics system will be usable at stroke patients’

homes after their discharge from the hospital, in

order to improve personal independence. It provides

immediate feedback on user performance using a

decision support architecture. The feedback will be

provided to both the patient and the health care

professionals with in-depth considerations for

security and confidentiality. The SCRIPT tele-

robotics system will be beneficial to improve arm

and hand function of stroke patients, while reducing

hospital and home visits and having a large impact

on reducing hospital costs.

During design and development, the system is

adapted to user requirements. The project evolves

from focus on user feedback during technology

development (presently ongoing) and user

acceptance during initial phases of try-out and

testing, to analyses of added value and impact of

such services applied at the patient’s home, for

additional important insight in contributing factors

to success of home application.

ACKNOWLEDGEMENTS

All partners of the SCRIPT consortium are

acknowledged for their contributions and valuable

input to the project: University of Hertfordshire (F.

Amirabdollahian, K. Dautenhahn, S. Gorham, A.

Basteris, N. Rahman), RU Robots (G. Pegman, J.

EHST/ICGREEN 2012

Foley), University of Sheffield (G. Mountain, N.

Nasr), University of Twente (A. Stienen, S. Ates),

Roessingh Research and Development (J. Buurke,

G. Prange, S. Nijenhuis, H. Hermens, H. Rietman),

MOOG BV (P. Lammertse), San Raffaele S.p.A. (A.

Cesario, L. Rossini), User Interface Design (J.

Schäfer).

The SCRIPT (Supervised Care &

Rehabilitation Involving Personal Tele-robotics)

project is partially funded under grant 288698 of the

framework of the European Commission (theme

3; Information and Communication Technologies).

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SCRIPT: Tele-robotics at Home - Functional Architecture and Clinical Application