ATP: Aqua Therapy for Patients, a New Approach for Water

Rehabilitation Follow-up with Connected Devices Linked with a

Serious Game

B. Martins

, A. Amiens

, C. Adamo

, M. Ascoet

and F. Barbot

Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências da Universidade de Lisboa,

Campo Grande, 1749-016, Lisboa, Portugal

Université de Technologie de Compiègne, Rue Roger Coutolenc, 60200, Compiègne, France

Institut de Recherche Biomédicale des Armées, D19, 91220, Bretigny-sur-Orge, France

Inserm CIC 1429, Hôpital Raymond-Poincaré, AP—HP, 104 Boulevard Raymond Poincaré, 92380, Garches, France

Keywords: Aquatic Therapy, Rehabilitation, Connected Devices, Serious Game.

Abstract: Rehabilitation is a public health issue that addresses the societal and economic problem of loss of autonomy.

Following a rehabilitation program may require an effort of movement and consistency for people with

motor difficulties who sometimes lack interest in this physiotherapy period that is difficult to concentrate

on. Thus, the ATP project proposes to improve the use of lower limb water rehabilitation by proposing a

device combining the use of sensors for direct biofeedback and serious game aspects to increase patient

motivation. The equipment will facilitate real-time monitoring and learning of rehabilitation. In addition, the

device will allow the physiotherapist, through information management and processing software, to

program personalized movement sequences based on each patient's pathology and monitor their progress

throughout the rehabilitation session and throughout the entire program. At each stage, the needs of

professionals and patients will be taken into account to ensure the success of rehabilitation processes.

1 INTRODUCTION

In the world, there are around 69 million traumatic

injuries, being traumatic brain injuries (TBI) one of

the leading causes of death and disability, about 15

million strokes and it is expected that 1 in 6 people

will have a stroke (Johnson and Griswold, 2017).

These problems, most of the time, cause motor

disorders like lower limbs incapacitating, and this

incapacity places a burden on health services due to

long physiotherapy period and sometimes permanent

disability of patients. Therefore, it is necessary to

find solutions that allow these patients to recover in

a quickly, effectively and less painful way.

1.1 Aquatic Therapy

The use of aquatic therapy was born after the Second

World War as a re-education technique for certain

neurological deficits such as polio (Kemoun and

Watelain, 2006). The aquatic environment thus

seems to have a large potential for rehabilitation,

whether for the treatment of acute traumas,

musculoskeletal disorders, neurological problems,

orthopaedic or rheumatological problems,

cardiopulmonary problems or by keeping fit in the

face of chronic diseases. Thanks to its clinical

adaptability, the practitioner can program therapies

adapted to a population of patients with diverse

pathologies.

From a physiological point of view, immersion

in an aquatic environment has many biological

effects, using all homeostatic systems (Becker,

2009). They are generally classified in 4 categories:

hydrostatic mechanics composed in particular of

Archimedes' thrust, hydrodynamic mechanics, the

physiological effect of water (temperature), and

psychological.

Indeed, according to Archimedes' theorem

"Anybody immersed in a fluid [...] undergoes a

vertical force [...] opposed to the weight of the

displaced fluid volume". This means that when the

patient is immersed up to the belly button, his

perceived weight represents 50% of his actual

weight. This allows the patient to feel lighter and

Martins, B., Amiens, A., Adamo, C., Ascoet, M. and Barbot, F.

ATP: Aqua Therapy for Patients, a New Approach for Water Rehabilitation Follow-up with Connected Devices Linked with a Serious Game.

DOI: 10.5220/0007697306270634

In Proceedings of the 12th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2019), pages 627-634

ISBN: 978-989-758-353-7

627

freer, and thus reassured. These effects combined

with the hydrostatic pressure also allow an elevation

of the centre of gravity as well as an easing of the

maintenance of static and dynamic equilibrium.

In addition, the hydrostatic pressure, associated

with the viscosity of the medium, is at the origin of

exteroceptive sensory stimuli. The immersion of the

body in the water seems to cause a better perception

of the position of the patient’s limbs. On the same

idea, resistance to displacement seems to enhance

both exteroceptive and proprioceptive information,

thus allowing a better awareness of the "overall body

pattern during movement". Moreover, by a

mechanism still little known, it seems that the

hydrostatic pressure, by intensive stimulation of the

baresthetic receptors, would cause an analgesic in

the joints. This theory is known as gate control

system. This effect would improve the functional

abilities of the patient. In fact, the patient suffers less

and this induces a desire for movement hence easier

and therefore faster rehabilitation (Geytenbeek,

2001; Honda and Hiroharu, 2012).

These effects also make it possible to reduce the

stresses exerted on the joints. Therefore, in the event

of a fracture or arthroplasty (Medical Advistory

Secretariat, 2005; Gibson and Shields, 2015; Łyp et

al., 2016), the weight reduction of the body will

allow the patient to resume more easily and quickly

support on his leg, and relearn the normal pattern of

walking. This can reduce the use of medicines.

The hydrostatic pressure would also intervene on

the breathing phenomena by acting on the resistance

at the level of the diaphragm and on the swelling of

the abdomen. The temperature of water also plays a

role on the re-education. Indeed, the heat relaxes the

muscles, because of dilation of blood vessels

(Kemoun and Watelain, 2006; Becker, 2009).

Some studies (Rahmann etal., 2009; Stockton

and Mengersen, 2009; Villalta and Peiris, 2013)

have wondered what are the interests and

disadvantages of potential wounds of postoperative

aquatic therapy. According to these articles, the

aquatic therapy would improve functional

rehabilitation and would not increase the risk of

adverse effects related to wounds after surgery.

The article (Giaquinto et al., 2010) describes that

after a total knee intervention, aquatic therapy

seemed beneficial because all treated patients had

lower arthritis pain scales. In addition, patients

reported a pleasant sensation of safety, allowing

them to be rehabilitated more quickly.

In summary, what we know is that at the

musculoskeletal level, the use of water properties

allows a better rehabilitation through several effects:

● Musculoligamentary circulation by increasing

oxygen supply and improving metabolic waste

disposal;

● Decrease in potential edema;

● Modular muscle toning;

● Reduction of joint constraints by a work in

discharge;

● Relaxing and analgesic effect of immersion,

especially on chronic pain;

● Sensory stimulation, in the case of a significant

postural deficit, for example;

● Stimulation of afferent fibres in subjects whose

sensitivity is impaired;

● Proprioception and better perception of the body

diagram;

● Improved motor coordination and balance by

using the inertia of water during central nervous

system dysfunction;

The articles, devoted to the study of the benefits of

water, demonstrate that the fields of application of

immersion in water are very wide and may be

suitable for a large part of the population: athletes,

paediatrics, disorders mentioned above, geriatrics

and obese persons.

1.2 Existing Solutions

On the market of water rehabilitation, several

companies propose therapy pools and underwater

treadmills. They all take advantage of this

supportive environment. The technologies combine

large boxes equipped a with treadmill on the ground

or specific water resistance jets. The water level is

adjustable in term of height in most cases. As a

consequence, the exercise can be adapted to adults

as well as children.

The applications are diverse: sport performance

purposes, recovery from injuries, weight challenge,

gait re-education after neurological disorders,

strokes… Only a small proportion of these kind of

products are registered as medical devices and they

do not record clinical parameters. The association of

such devices with connected gaming has not been

seen on the market for the moment.

Other systems exist on the market, like anti-

gravity treadmills using differential air pressure

technology to reduce the gravitational forces and

therefore permit moving without pain, reproducing a

kind of “levitation” environment.

The common goal of these technologies is a

feeling of body weight reduction and a minimized

joint impact. It is a great alternative to land-based

therapy, especially in the early stage of recovery.

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1.3 Serious Game

1.3.1 Concept

Defining a serious game is not something easy

because of the amount of classifications and criteria.

If there is only one thing to remember about it, this

should be that the serious game combines the

enjoyment experience of the game, with a useful

objective. According to (Alvarez and Damien,

2003), it could be summarized by the following

relationship:

Serious Game

= Utilitarian function(s) + Video Game

The serious game concept is, above all, a game

which engenders satisfaction and challenge to the

player. The ‘serious’ goal can be related to many

fields such as defense, health, education, learning,

ecology and so on (Alvarez and Damien, 2003). At

the end, the outcome can be sending a message,

sharing knowledge or developing and improving

skills.

In the Malone’s theory (Malone, 1981), three

characteristics compose an intrinsically motivation

instructional environment: the challenge, the fantasy

and the curiosity.

● The challenge is provided by a goal whose

attainment is uncertain, depending of the

difficulty for example. The goal is one of the

reasons why a player wants to play. It uses the

player’ skills and takes part in the fantasy of the

game.

● The fantasy is, in a manner of speaking, the story

of game and how it is related. A game can have

an infinity of universes – real or not – and

equally many manners to relate it.

● The curiosity is a subtle balance between the

player expectations’ and the game evolution.

1.3.2 Place of the Serious Game in

Rehabilitation

Many studies in virtual reality or based on serious

games have shown the interest of these

environments that offer the opportunity to

significantly expand the variety of applications with

a positive effect on patient motivation (Sorita et al.,

2013). In other articles, authors raised this problem

of motivation particularly because of the

repetitiveness of the exercises (Rego et al., 2010).

For instance, (Burke et al., 2009) talk about the

“lack of patient interest in performing repetitive

tasks and in ensuring that they finish the treatment

program”. It is indeed recognized that a greater

involvement of the patient in his re-education will

lead to an interest in dedicating more time to the

activities that constitute it. So it seems obvious that

using serious game increase the patient involvement.

Not directly in the rehabilitation, but in an enjoyable

activity that makes him focus on something else less

boring or less exhausting.

To (Fovet et al., 2017), there are three important

levels for feedback in a therapy program: the game

feedback, the psychophysiological feedback and the

therapist feedback. Thus, in rehabilitation, the use of

serious games could not only improve the

motivation of patients, but also deliver patients

returns in a funny way regarding their performance

or in response to unsuitable movements. Thus, this

promotes learning or reprogramming of movements

sequences required to perform the requested activity.

The psychophysiological feedback refers to the

biofeedback that delivers a real time information

about the patient, inside the serious game and during

his session. A serious game is only one more tool in

the physiotherapist’ rehabilitation toolbox that is

why the therapist’ feedback is essential to support

and to advice the patient (Fovet et al., 2017).

2 ATP: AQUA THERAPY FOR

PATIENTS

The project was born as part of the ClinMed2018

Summer School granted by EIT Health. The purpose

of this 10-days course was to conceptualize an

innovative medical device from the needs identified

during our first three days in a hospital immersion.

The following days of this program gave us an up-

to-date general perspective of the life cycle of a

medical device: from the initial concept until it

reaches the market. These different lectures given by

professionals in the field of medical devices as well

as our different school backgrounds, within the

team, allowed us to develop our idea to a concept of

medical device.

It was at the Garches hospital, in the

rehabilitation department, that our idea of aquatic

therapy was born. Indeed, it is during the visits of

the different units of the hospital that some clinical

needs have been identified. After neurological

disorders (such as post-stroke patients with

hemiparesis, foot drop, paralysis and spasticity for

example), traumatic injuries or surgeries, it may be

difficult to regain mobility in the beginning of

recovery. In fact, because of long joint

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629

immobilisation, fear and pain is usually felt when

training mobility. To facilitate the rehabilitation

early process, water environment offers several

advantages as explain in introduction. Furthermore,

balneotherapy pools are only available in big

functional rehabilitation centres and private clinics

that can afford and support associated maintenance

costs. However, smaller clinical facilities have not

enough space and resources to use hydrotherapy.

Therefore, some patients have to travel kilometres to

find this specific solution. Our turnkey solution will

allow the practitioners to benefit from hydrotherapy

without requiring a swimming pool.

The ATP device consists of four main parts:

● Water chamber where the patient will enter, and

the water rises until the adapted level;

● Connected devices: a carpet with force sensors

inside and waterproof cameras;

● Serious games for the patient to interact with;

● Software and database, which integrates the

interface used by the physiotherapist and doctor

and a cloud.

Therefore, in this section, it is described in detail the

main parts of the device.

2.1 Water Chamber

The water chamber (figure 1) consists of three parts

of glass walls (the lateral sides and a door), and a

stainless-steel part comprising the removable screen

and the corners. It includes the connected carpet that

is sealed at the bottom of the chamber. Two

removable handrails are present on each side, so

they can be adjusted to the right height of each

patient. They allow the patient to maintain the

balance ensuring his safety. The cabin can be filled

with an adjustable quantity of water according to the

size of the patient and the body clinical target. The

water can reach the hip of a patient.

Figure 1: Representation of the water chamber of the ATP

device.

It also includes a reservoir and water filters that

can be placed in a different room to allow better

space management. The connection between the

reservoir and the chamber is made through

plumbing.

2.2 Connected Devices

The ATP is equipped with a carpet with the force

sensors inside and waterproof cameras. These

devices allow to test and track the patient’s

movement.

2.2.1 Connected Carpet

It is composed by an underwater force platform.

Such platform has been identified in the market. The

sensors that composed the force platform will be

placed in the floor to avoid no contact with water,

and the electronic parts will be placed in the

waterproof box outside the water chamber. The

collected information will then be sent to a computer

device

via Wi-Fi for data processing.

Figure 2: Representation of feet placement.

This arrangement, presented in figure 2, is

related to the movements that the patient must

perform in accordance with the serious games (that

will be explained next) projected on the screen. It

can be done to place his left foot forward, on the

right or take a step back. It is the same thing for the

right foot. In addition, it is possible to take more

support on one of his feet and the sensors in the

platforms will explain in real time the plantar

pressure of the patient. In addition, the carpet can

become unstable, according to the willingness of the

physiotherapist with a moving system, in order for

the patient to train his balance and posture. The

carpet allows to have information of the

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pedobarography and stabilometry of the patient, in

order to know the pressure exerted on the plantar

level, and if he places his foot correctly on the

sensors. The articles (Rosário, 2014; Skopljak et al.,

2014; Notarnicola et al., 2018) show that

pedobarography seems to be a good method for

monitoring effects of rehabilitation in a non-invasive

way. In fact, it’s important to have the evolution of

the patient, this device can allow knowing if the

patient takes confidence and improves his way of

walking.

2.2.2 Waterproof Cameras

The chamber will be equipped with cameras that

will track the patient's movements. These devices

will enable the practitioner to ensure that the patient

performs the right movements and the right

placements. It also allows following the evolution of

the rehabilitation in addition to the information

given by the sensors present in the carpet. The

cameras allow a following of the angles at the knees

and ankles.

It may be composed by a set of 4 cameras at 4,

located at the middle of each side, to get the best

viewing angles for each leg.

2.3 Serious Game

2.3.1 Game Concept

The serious game integrated into the ATP device

would be the following: the person in rehabilitation

will discover the world through the theme of travel

and culture. This thematic is quite universal and

intergenerational.

The principle of this serious game is to display

on the screen in front of the patient a world map. At

the beginning, it can be assumed that the player is in

France or in one town in particular. The goal is to

travel all around the world, to visit countries and

towns and to discover different cultures and famous

locations. Challenge is brought by the way of

transport and the new countries and places to

unlocked. The patients’ curiosity is maintained by

the cultural aspects: customs, history, and so on.

2.3.2 Relation between the Game and the

Rehabilitation

Conception of the serious game must be adapted

according to the rehabilitation needs. This one will

use the patient movements in the water and his

pressures on the carpet to move on the serious game

map. Depending on the movements done by the

patient, the four motion cameras and the sensors in

the carpet will record the positions of his legs and of

his feet. All that information will be transmitted to

the practitioner’s software and analyse in one hand

by the computer to move forward in the serious

game; in another hand, by the professional to

evaluate the progression of the patient in his

rehabilitation.

2.4 Software and Database

The last part of the device will be mainly dedicated

to the physiotherapist and will have a double utility.

The first is to centralize the information gathered

during the session, process and share it and the

second is to manage the application of the serious

game for the patient's rehabilitation session.

2.4.1 Software

Recording and the processing of the data from the

sensors and in a bigger dimension the storage and

exploitation of these in medical purposes is the first

goal of the software.

The software has to be able to restitute

information understandable by the practitioner, in

particular the physiotherapist. For instance, a

representation of the gait and a restitution of where

and how the patient puts his feet on the carpet

(pedobarography). That is very important to the

professional as an indicator of good evolution of the

rehabilitation. In addition, this could be a source of

advices if the patient’s movements are not correctly

done.

The second function is the management of the

serious game. From the interface of the software, a

specific part will be dedicated to the Serious Game.

Like that, before each session, the practitioner just

will have to set the serious Game (movements the

patient has to work on, duration of the exercises,

difficulty, and so on). At the end, the progression of

the patient is recorded as a track of his work. The

progression will be symbolized by the bonus and the

evolution of the patient in the gameplay.

2.4.2 Database

Another aspect of the device is to centralize all the

information gathered by the sensors and the cameras

during the rehabilitation. Two objectives for that: the

big data and the share of the information about one

patient to all the health care professional around

him. Indeed, we already know that only a little part

of this kind of information is shared between the

medical staff. The hypothesis is the more the

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professionals will have interaction around one

patient in rehabilitation, the more his rehabilitation

will be efficient in all its dimensions (physical,

psychological, and so on…).

The expression ‘Big data’ has to be understood

like a big amount of information about the gait in the

rehabilitation context in order to improve the

knowledge of the professionals: a better

comprehension of its mechanic can be helpful to

find indicators to predict the healing.

2.5 Our Added Value

Our product aims to allow the motor rehabilitation

of people suffering from motor disorders such as

neurological disabilities, strokes, traumatic injuries

(ankle, knee, and hip), orthopaedics post-operative.

The project has four main added values:

 The use of the water for the re-education;

 The use of the sensors to follow the evolution of

the rehabilitation of the patient;

 The water chamber which allows a more

practical rehabilitation for the patients in private

clinics;

 And the serious game that makes the re-

education more attractive and motivating for the

patients.

Indeed, the novelty of this system is based on the use

of a serious game for rehabilitation in water. There

are a lot of benefits to use the water for

rehabilitation, as we said before. The water is use as

a supportive environment. In fact, the weight

sensation is reduced, enabling to train the motricity

in a painless way, because of the decrease pressure

on joints and bones to resume support on the legs

faster. Water resistance enhance also the muscular

rehabilitation. So, thanks to its qualities, water can

allow people who do not stand on their feet on the

ground, to regain self-confidence inside the water

which allows them to relearn how to walk. Finally,

all the benefits of water can reduce the time of

rehabilitation in comparison with a conventional

therapy (Geytenbeek, 2001; Honda and Hiroharu,

2012).

The second added value concerns the

combination of different sensors that track the

patient's progress in real time. In other words, his

plantar pressure will be used to verify that he

correctly places his foot thanks to the plantar

platforms, and the waterproofs cameras for tracking

the patient's movement.

The value added by the box comes from the fact

that there are not enough balneotherapy centres.

Patients often have to walk miles to find a centre

that allows this kind of rehabilitation. The idea

would be to equip private clinics with these boxes to

allow the patient to have easier access. These boxes

require the presence of physiotherapists to check the

progress of the session and adjust the serious game

to the pathology of the patient.

Finally, the serious game makes the therapy

more attractive to the patient, and possibly reduces

the orthopaedic recovery time.

3 DEVELOPMENT PLAN

3.1 Regulatory Strategy

The registration requirements and thus the technical

file are related to our medical device class. Each

country has its own classification rules and we will

focus here on European directives. So, according to

the clinical use we provide for the device, one of the

first things is to define the class of the medical

device, following the VIII Annex classification of

the Regulation (EU) 2017/745 of the European

Parliament and of the Council’ of 5 April 2017 on

medical device’ (European Parliament and Council

of the European Union, 2017).

The intended purpose is the water rehabilitation

of the lower-limb. It’s a non-invasive device, with

transient duration (less than 60 minutes). The device

depends on a source of electrical energy, so it is an

active device, has monitoring elements and includes

software. Considering all these elements, ATP is a

Class I medical device.

As consequence, the conformity evaluation

procedure only depends on the manufacturer’s

responsibility (no intervention of the notified body).

As the device has a measure function, a production

quality assurance must be implemented.

3.2 Validation and Verifications Tests

In order to validate and ensure reliability, the device

must be properly tested to verify the operating

conditions, effectiveness and safety of its

functionalities. Therefore, verification and validation

tests must be carried out.

The verification tests try to determine whether

the result at each stage in the development process

satisfies the needs of the next phase. The primary

objective is to detect as many errors as possible,

whether conception, design or assembly errors.

There are several tests being that for this equipment

include:

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 Measurement of the specifications of the

components: functioning of the sensors

(sensibility of the sensors, transmission

capacity…), verification of the proper placement

of the waterproof cameras to follow the

movements of the patient optimally, and so on;

 Measurement of the speed of water filling in the

cabin and the adjustment of the temperature, as

well as the sliding of the bars;

 Overheating: check if the device does not

overheat with continuous use throughout the day;

 Power supply: check if all devices are properly

powered;

 Study of adverse conditions: verify if the system

is minimally resistant to conditions like stress

and shock;

 Software study: verify if the application does not

block with a continuous use throughout the day.

Validation tests are performed during or at the end

of the development process to assess whether the

specified requirements of the device or a component

are met. These tests, carried out according to a

complete risk analysis, include validate the

effectiveness and precision of the sensors to acquire

measurements and also the usability of the device.

The usability tests will include a large patient

population to test the use of the chamber (patient

size, weight, age). These tests aimed to ensure issues

like the dimensions of the devices, the sensors

functioning on the human body. It will be necessary

to validate the use of these devices by clinical tests.

For the software, we need to do several tests

based on users’ stories to prove the usability of it,

with wireframes first, then with a prototype. The aim

is to ensure ourselves of the usability of the

software.

For the serious game they must be developed and

designed with a strict collaboration between

physiotherapists, patients and developers, so the

specific needs of both, the professional, the patient

and the rehabilitation will be respected in the

specifications book. About the tests of the serious

game, it is the same process as for the software:

personas, experience maps, wireframing and

prototype.

Finally, all along the life of the system, risk

matrices will be used to ensure its proper

functioning and to prevent the emergence and

neutralisation of possible risks.

3.3 Economic Model

In order to have a successful business strategy, we

identified who are the stakeholders and what is the

clinical pathway. The physiotherapist and private

clinical centre may profit from the investment on our

product for different reasons. First, if we consider

the doctor-physiotherapist link: the physiotherapist

equipped with the device may be recommended and

thus privileged by the patient for his treatment.

Considering the patient-physiotherapist link: this

attractive and powerful equipment brings an added

value for the physiotherapist renown thanks to fattest

recovery; on this point is also important to refer, as a

future step, that one trend of the rehabilitation

market relies on the “digital” or “e-tech” enthusiasm

in our modern society, above all for the sporty

community. Indeed, consumerism begins to reach

healthcare and the patients ask for the best care.

Therefore, as we intend to sell our device

directly to private physiotherapy clinics, we are

going to adopt a B2C relationship. For that, we

would disclose our products from unpaid channels,

with the issuance of a website with information and

product specifications, and paid channels, such as

medical equipment exhibition, direct email contact

and congresses. In order to have a business strategy,

we decided to adopt the Continuity Income Method

Business Model - along with the sale of the product

(chamber of water and sensors and a user

formation), there would also be a loyalty of the

cloud and assistance of the product with an annual

fee (subscription fees).

4 CONCLUSIONS

As water provides essential advantages for early

physical rehabilitation like buoyancy, weightlessness

and confidence for moving, underwater

rehabilitation is highly valued. To meet to the

demand of physiotherapists without aquatic

facilities, the ATP project proposes to develop water

rehabilitation for the assessment and training of

lower limbs capacities with connected devices

toward measure effort and feedback. The project

also depends on the use of a serious game which is

not only to improve the motivation of patients but

also to deliver biofeedback in a fun way about their

performance or in response to potential incorrect

movements.

ACKNOWLEDGEMENTS

We thank Frédéric Barbot for his help in the first

days of our immersion course, and for his

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involvement during the months that followed. Thank

you to the entire Garches CIC team who welcomed

us during our immersive experience. Thanks to EIT

Health and the speakers for giving us the

opportunity to participate in the summer school and

to be able to work intensively on our project while

giving us courses and advice very useful to the

development of our concept.

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