Posts Tagged Telemedicine

[ARTICLE] Wearable technology in stroke rehabilitation: towards improved diagnosis and treatment of upper-limb motor impairment – Full Text

Abstract

Stroke is one of the main causes of long-term disability worldwide, placing a large burden on individuals and society. Rehabilitation after stroke consists of an iterative process involving assessments and specialized training, aspects often constrained by limited resources of healthcare centers. Wearable technology has the potential to objectively assess and monitor patients inside and outside clinical environments, enabling a more detailed evaluation of the impairment and allowing the individualization of rehabilitation therapies. The present review aims to provide an overview of wearable sensors used in stroke rehabilitation research, with a particular focus on the upper extremity. We summarize results obtained by current research using a variety of wearable sensors and use them to critically discuss challenges and opportunities in the ongoing effort towards reliable and accessible tools for stroke rehabilitation. Finally, suggestions concerning data acquisition and processing to guide future studies performed by clinicians and engineers alike are provided.

Introduction

Stroke is one of the leading causes of disability worldwide [], with a global prevalence estimated at 42.4 million in 2015 []. Stroke results in permanent motor disabilities in 80% of cases []. During the acute and subacute stages (< 6 months after stroke []), patients receive rehabilitation therapies at specialized healthcare centers, consisting of an iterative process involving impairment assessments, goal definition, intervention, and progress evaluation []. After being discharged from the rehabilitation center (i.e. after entering the chronic stage, e.g., 6 months after stroke), 65% of patients are unable to integrate affected limbs into everyday-life activities [], showing a need for further treatment. Phrased differently, the rehabilitative process after stroke depends on the effective assessment of motor deficit and congruent allocation to treatment (diagnostics), accurate appraisal of treatment effects (recovery/adaptation evaluation), and prolonged treatment for continuous recovery during the chronic stage (extended training).

Each of these three aspects present practical challenges. Assigned treatments depend on the assessed early-stage disability []. A variety of assessment scales exist to evaluate motor impairment after stroke, designed to capture aspects such as joint range of motion (ROM), synergistic execution of movements, reaching and grasping capabilities, object manipulation, etc. []. These assessments are normally applied by specialized medical personnel, which entails certain variability between assessments []. Besides consistency in repeated measurements, some scales like the Fugl-Meyer assessment (FMA) [], are unable to capture the entire spectrum of motor function in patients due to limited sensitivity or ceiling effects [].

In addition to thorough standardized assessment scales, progress in patients is observable during the execution of activities of daily living (e.g., during occupational therapy sessions). Nevertheless, task completion not always reflects recovery, as patients often adopt different synergistic patterns to compensate for lost function [], and such behavior is not always evident.

Main provision of rehabilitation therapies occurs at hospitals and rehabilitation centers. Evidence of enhanced recovery related to more extensive training has been found [], but limited resources at these facilities often obstruct extended care during the chronic stage. This calls for new therapeutic options allowing patients to train intensively and extensively after leaving the treatment center, while ensuring the treatment’s quality, effectiveness and safety.

Wearable sensors used during regular assessments can reduce evaluation times and provide objective, quantifiable data on the patients’ capabilities, complementing the expert yet subjective judgement of healthcare specialists. These recordings are more objective and replicable than regular observations. They have the potential of reducing diagnostic errors affecting the choice for therapies and their eventual readjustment. Additional information (e.g., muscle activity) extracted during the execution of multiple tasks can be used to better characterize motor function in patients, allowing for finer stratification into more specific groups, which can then lead to better targeted care (i.e. personalized therapies). These devices also make it possible to acquire data unobtrusively and continuously, which enables the study of motor function while patients perform daily-life activities. Further, the prospect of remotely acquiring data shows promise in the implementation of independent rehabilitative training outside clinics, allowing patients to work more extensively towards recovery.

The objective of this review is to provide an overview of wearable sensors used in stroke rehabilitation research, with a particular focus on the upper extremity, aiming to present a roadmap for translating these technologies from “bench to bedside”. We selected articles based on their reports about tests conducted with actual stroke patients, with the exception of conductive elastomer sensors, on which extensive research exists without tests in patients. In the section “Wearable devices used in stroke patients”, we summarize results obtained by current research using a variety of wearable sensors and use them to critically discuss challenges and opportunities in the ongoing effort towards reliable and accessible tools for stroke rehabilitation. In the “Discussion” section, we present suggestions concerning data acquisition and processing, as well as opportunities arising in this field, to guide future studies performed by clinicians and engineers alike.

Wearable devices used in stroke patients

Recent availability of ever more compact, robust and power-efficient wearable devices has presented research and development groups in academia and industry with the means of studying and monitoring activities performed by users on a daily basis.

Over the past years, multiple research groups have worked towards a reliable, objective and unobtrusive way of studying human movement. From the array of sensors and devices created, a few have gained popularity in time due to their practicality. The next subsections will focus on the wearable devices most frequently used in the study of human motion, with special emphasis on monitoring of upper limbs in stroke patients.

Inertial measurement units (IMUs)

Inertial measurement units (IMUs) are devices combining the acceleration readings from accelerometers and the angular turning rate detection of gyroscopes []. Recent versions of such devices are equipped with a magnetometer as well, adding an estimation of the orientation of the device with respect to the Earth’s magnetic field []. A general description of how inertial data are used to extract useful information from these devices is offered by Yang and Hsu []. High-end IMUs used for human motion tracking, such as the “MTw Awinda” sensor (Xsens®, Enscheda, Overijssel, The Netherlands) [], acquire data at sampling rates as high as 1 kHz (sensitivities of ±2000 deg/s, ±160 m/s2, ±1.9 G). More affordable sensors (e.g. “MMR” (mbientlab Inc.®, San Francisco, California, USA) []) stream data at 100 Hz (max sensitivities of ±2000 deg/s, ±16 g, 13 G). The necessary sampling rate depends on the application, and must be defined such that aliasing is avoided (i.e. Nyquist rate, 2 times the frequency of the studied phenomenon). Figure 1 shows an example of motion tracking using these devices.

Diagnostics

Multiple scales exist for assessing motor function in stroke patients []. However, limitations exist in terms of objectivity and test responsiveness to subtle changes [], as well as on the amount of time needed to apply these tests. Therefore, several research groups have focused on the use of IMUs to assess motor function more objectively. Hester et al. [] were able to predict hand and arm stages of the Chedoke-McMaster clinical score, while Yu et al. [] built Brunnstrom stage [] classifiers, assigning each patient to one of six classes of synergistic movements in affected limbs. The Wolf Motor test [], the FMA [] and the Action Research Arm Test (ARAT) [], frequently used to assess motor function in clinical settings, have also been automated.[…]

 

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[REVIEW] Strategies to implement and monitor in-home transcranial electrical stimulation in neurological and psychiatric patient populations: a systematic review – Full Text

Abstract

Background

Transcranial electrical stimulation is a promising technique to facilitate behavioural improvements in neurological and psychiatric populations. Recently there has been interest in remote delivery of stimulation within a participant’s home.

Objective

The purpose of this review is to identify strategies employed to implement and monitor in-home stimulation and identify whether these approaches are associated with protocol adherence, adverse events and patient perspectives.

Methods

MEDLINE, Embase Classic + Embase, Emcare and PsycINFO databases and clinical trial registries were searched to identify studies which reported primary data for any type of transcranial electrical stimulation applied as a home-based treatment.

Results

Nineteen published studies from unique trials and ten on-going trials were included. For published data, internal validity was assessed with the Cochrane risk of bias assessment tool with most studies exhibiting a high level of bias possibly reflecting the preliminary nature of current work. Several different strategies were employed to prepare the participant, deliver and monitor the in-home transcranial electrical stimulation. The use of real time videoconferencing to monitor in-home transcranial electrical stimulation appeared to be associated with higher levels of compliance with the stimulation protocol and greater participant satisfaction. There were no severe adverse events associated with in-home stimulation.

Conclusions

Delivery of transcranial electrical stimulation within a person’s home offers many potential benefits and appears acceptable and safe provided appropriate preparation and monitoring is provided. Future in-home transcranial electrical stimulation studies should use real-time videoconferencing as one of the approaches to facilitate delivery of this potentially beneficial treatment.

Introduction

Transcranial electrical stimulation (tES) is a technique used to modulate cortical function and human behaviour. It involves weak current passing through the scalp via surface electrodes to stimulate the underlying brain. A common type of tES is transcranial direct current stimulation (tDCS). Several studies have demonstrated tDCS is capable of modulating cortical function, depending on the direction of current flow [123]. When the anode is positioned over a cortical region, the current causes depolarisation of the neuronal cells, increasing spontaneous firing rates [4]. Conversely, positioning the cathode over the target cortical region causes hyperpolarisation and a decrease in spontaneous firing rates [4]. This modulation of cortical activity can be observed beyond the period of stimulation and is thought to be mediated by mechanisms which resemble long term potentiation and depression [5]. Along similar lines, transcranial alternating current stimulation (tACS) and transcranial random noise stimulation (tRNS) are also forms of tES. Both tACS and tRNS are thought to interact with ongoing oscillatory cortical rhythms in a frequency dependent manner to influence human behaviour [678].

The ability of tES to selectively modulate cortical activity offers a promising tool to induce behavioural change. Indeed, several studies have demonstrated that tES may be a favourable approach to reduce impairment following stroke [9], improve symptoms of neglect [10], or reduce symptoms of depression [11]. While these results appear promising, there remains debate around technical aspects of stimulation along with individual participant characteristics that may influence the reliability of a stimulation response [1213141516171819202122]. However, current evidence does suggest that effects of stimulation may be cumulative, with greater behavioural improvements observed following repeated stimulation sessions [20]. Furthermore, tES has shown potential as a tool for maintenance stimulation, with potential relapses of depression managed by stimulation which continued over several months [2324]. Therefore, it may be that repeated stimulation sessions will become a hallmark of future clinical and research trials aiming to improve behavioural outcomes. This would require participants to attend frequent treatment sessions applied over a number of days, months or years. Given that many participants who are likely to benefit from stimulation are those with higher levels of motor or cognitive impairment, the requirement to travel regularly for treatment may present a barrier, limiting potential clinical utility or ability to recruit suitable research participants [25]. In addition, regular daily treatments would also hinder those who travel from remote destinations to receive this potentially beneficial neuromodulation. Therefore, there is a requirement to consider approaches to safely and effectively deliver stimulation away from the traditional locations of research departments or clinical facilities.

One benefit of tES over other forms of non-invasive brain stimulation, such as repetitive transcranial magnetic stimulation, is the ability to easily transport the required equipment. This opportunity may allow for stimulation to be delivered in a participant’s home, which could represent the mode of delivery for future clinical applications. However, it may be unreasonable to expect that a participant would be capable of managing delivery of tES alone and would likely require some form of training and/or monitoring [25]. Although tES is considered relatively safe [26], stimulation should be delivered within established guidelines to avoid adverse events [27]. Inappropriate delivery of stimulation could result in neural damage, detrimental behavioural effects, irritation, burns or lesions of the skin [282930313233]. Therefore, in order to deliver stimulation safely to the appropriate cortical region, it is likely that in-home stimulation may require some form of monitoring [25].

It is currently unclear what the best approach is to implement and monitor in-home tES. An early paper proposed several guidelines to perform in home tES [34]. However, these guidelines were not based on evidence from published clinical trials as there were none available at the time of publication. One recent systematic review sought to discuss current work in this area and highlighted the need for further research to investigate safety, technical monitoring and assessment of efficacy [35]. Given the recent, and growing, interest in home-based brain stimulation, we felt it was now pertinent to conduct a review to specifically identify strategies employed to implement and monitor the use of in-home tES in neurological and psychiatric populations. The secondary questions were to report protocol adherence, adverse events and patient perspectives of in-home tES. Understanding optimal treatment fidelity for in-home brain stimulation will be instrumental to achieving higher levels of tES useability and acceptance within a participant’s home.[…]

 

via Strategies to implement and monitor in-home transcranial electrical stimulation in neurological and psychiatric patient populations: a systematic review | Journal of NeuroEngineering and Rehabilitation | Full Text

Fig. 2 Cochrane risk of bias tool was used to assess quality of included studies

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[ARTICLE] A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems – Full Text

Abstract

The appropriate development of tele-rehabilitation platforms requires the involvement and iterative assessments of potential users and experts in usability. Usability consists of measuring the degree to which an interactive system can be used by specified final users to achieve quantified objectives with effectiveness, efficiency, and satisfaction in a quantified context of use. Usability studies need to be complemented by an accessibility assessment. Accessibility indicates how easy it is for a person to access any content, regardless of their physical, educational, social, psychological, or cultural conditions. This chapter intends to conduct a systematic review of the literature on usability and accessibility in tele-rehabilitation platforms carried out through the PRISMA method. To do so, we searched in ACM, IEEE Xplore, Google Scholar, and Scopus databases for the most relevant papers of the last decade. The main result of the usability shows that the user experience predominates over the heuristic studies, and the usability questionnaire most used in user experience is the SUS. The main result of the accessibility reveals that the topic is only marginally studied. In addition, it is observed that Web applications do not apply the physical and cognitive accessibility standards defined by the WCAG 2.1.

1. Introduction

Innovation and technological advances involve the offering of valuable products and services to improve the quality of life of citizens. In recent decades, the domain of telemedicine has reported advances in the control, monitoring and evaluation of various clinical conditions [1]. In the field of rehabilitation, numerous studies and state-of-the-arts from informatics perspective [2] and different areas of application [34], show the effectiveness and advantages of the use of remote rehabilitation (or tele-rehabilitation) [56]. Tele-rehabilitation aims to reduce the time and costs of offering rehabilitation services. The main objective is to improve the quality of life of patients [7]. Tele-rehabilitation cannot replace traditional neurological rehabilitation [8]. It is considered as a partial replacement of face-to-face physical rehabilitation [9]. Tele-rehabilitation uses mainly two groups of technologies: (1) wearable devices and (2) vision-based systems based on depth cameras and intelligent algorithms [10]. In [5], the authors describe and analyze some characteristics and typical requirements tele-rehabilitation systems.

Design and conception of tele-rehabilitations platforms that do not consider guidelines, metrics, patterns, principles, or practice success factors can affect the access to the service, the effectiveness, quality, and usefulness. It can cause problems of confusion, error, stress, and abandonment of the rehabilitation plan. Therefore, guaranteeing the correct use of these applications implies to incorporate different studies of usability in the life cycle of the interactive system. For this reason, aspects of human factors engineering in tele-rehabilitation systems have been studied with the aim of providing accessible, efficient, usable and understandable systems [1112].

User-centered agile development (UCD) approaches allows developers to specify and design the set of interfaces of any interactive system in a flexible and effective way [1314]. The agile development life cycle centered on user experience (UX-ADLC) allows iteratively evaluating system interfaces based on the results of the previous iteration. The evaluation also includes the errors and usability problems encountered [15]. Thus, usability studies are an essential aspect of technology development [16]. This is the reason why designers need to meet usability and user experience objectives while adhering to agile principles of software development. Formative and summative usability tests are methods of evaluating software products widely adopted in user-centered design (UCD) [15] and agile UX development lifecycle. Both approaches are frequently used in the development of software applications. Rapid formative usability should be carried out so as to fulfill UX goals while satisfying end users’ needs. Formative usability is used as an iterative test-and-refine method performed in the early steps of a design process, in order to detect and fix usability problems [15]. Summative usability allows for assuring, in later phases of the design, the quality of the user experience (UX) for a software product in development. The focus is on short work periods (or iterations) where usability tests (formative and summative) must be contemplated. This means that quick formative usability tests should be carried out to fulfill UX goals [17].

The ISO 9241-11 standard [18] is a framework for understanding and applying the concept of usability to situations in which people use interactive systems and other types of systems (including built environments), products (including industrial and consumer products) and services (including technical and personal services). Likewise, the usability standard ISO 9241-11 facilitates the measurement of the use of a product with the aim of achieving specific objectives with effectiveness, efficiency and satisfaction in a context of specific use [18].

Usability can be studied through software evaluation methods widely accepted in user centered design (UCD) [15]. It can be formative or summative [8]. Formative usability consists of a set of iterative tests carried out in the early stages of the design process. The aim of the tests is to refine and improve the software product, as well as to detect and solve potential usability problems. As a complement, the summative usability allows to obtain an evaluation of the user experience (UX) for a software product in development. Formative usability facilitates decision making during the design and development of the product, while summative usability is useful when studying user experience (UX).

Tullis and Stetson [19] evaluated the effectiveness of the most used questionnaires to measure the summative usability. The authors found that the System Usability Scale (SUS) [20] and the IBM Computer System Usability Questionnaire (CSUQ) [21] are the most effective. SUS provides a quick way for measuring the usability through user experience. It consists of a 10-item questionnaire with 5-likert scale range from “Strong Agree” to “Strongly Disagree.” The CSUQ focuses on three main aspects: (1) the utility, which refers to the opinion of users regarding the ease of use, the ease of learning, the speed to perform the operations, the efficiency in completing tasks and subjective feeling; (2) the quality of the information which studies the subjectivity of the user regarding the management of system errors, the clarity of the information and the intelligibility; and finally, (3) the quality of the interface which measures the affective component of the user’s attitude in the use of the system.

Large part of the tasks in the tele-rehabilitation systems are carried out by patients who require to treat a temporary disability. Considering the special needs of these users, usability evaluations alone cannot guarantee an appropriate design of the system. On the contrary, accessibility studies can provide the mechanisms to offer the same means of use to all users of any interactive system. A study combining usability and accessibility was presented in [22]. The study analyzes how remote and/or video monitoring technologies affect the accessibility, effectiveness, quality and usefulness of the services offered by tele-rehabilitation systems. To do this, the authors provide an overview of the fundamentals necessary for the analysis of usability, in addition to analyzing the strengths and limitations of various tele-rehabilitation technologies, considering how technologies interact with the clinical needs of end users such as accessibility, effectiveness, quality and utility of the service [22].

For many people, the Web is a fundamental part of everyday life. Therefore, a fundamental aspect to ensure the inclusivity of a Website is its accessibility. For example, people who cannot use their arms to write on their computer can use a mouth pencil [23]. Or someone who cannot listen well can use subtitles to understand a video. Also, a person who has a low vision can use a screen reader to listen what is written on the screen [24]. Therefore, Web accessibility means that people with disabilities can use the Web without any type of barriers [24]. There are several standards related to accessibility that provide guidelines and recommendations [25]. Some of the most important, according to the International Organization for Standardization (ISO), are the following ones:

  • ISO 9241: covers ergonomics of human-computer interaction.

  • ISO 14915 (software ergonomics for multimedia user interfaces): multimedia controls and navigation structure.

  • ISO CD 9241-151 (software ergonomics for World Wide Web user interfaces): designs of Web user interfaces.

  • ISO TS 16071 (guidance on accessibility for human-computer interface): recommendations for the design of systems and software applications that allows a greater accessibility to computer systems for users with disabilities.

  • ISO CD 9241-20: accessibility guideline for information communication, equipment and services.

The Web Accessibility Initiative (WAI) [26] from the World Wide Web Consortium (W3C) [27] develops Web Content Accessibility Guidelines (WCAG) [28] 2.0 (at present 2.1) that covers a wide range of recommendations for making Web contents more accessible. These guidelines were considered a standard in 2012, the ISO/IEC 40500. Complementary to these guidelines are the W3C User Agent Accessibility guidelines [29] (UAAG) and Authoring tool Accessibility guidelines [30] (ATAG), which addresses the current technological capabilities to modify the presentation based on the device capabilities and the preferences of the user.

The World Wide Web Consortium (W3C) provides international standards to make the Web as accessible as possible. It comprises the Web 2.0 Content Accessibility Guidelines (WCAG 2.0) [31], also known as the ISO 40500 [32], which are adapted to the European Standard called EN 301549 [33].

The current version of the accessibility guidelines is “Web Content Accessibility Guidelines 2.1” (WCAG 2.1) [23]. WCAG 2.1 consists of 4 principles, 13 guidelines and 76 compliance criteria. The four principles refer to [34].

Principle 1—perceptibility: refers to the good practices regarding the presentation of information and user interface components. It consists of 4 guidelines and 29 compliance criteria.

Principle 2—operability: the components of the user interface and navigation must be operable. It includes 5 guidelines and 29 compliance criteria.

Principle 3—comprehensibility: the information and user interface management must be understandable. It has 3 guidelines and 17 compliance criteria.

Principle 4—robustness: the content must be robust enough to rely on the interpretation of a wide variety of user agents, including assistive technologies. It includes a guideline and three compliance criteria.

Usability and accessibility can be combined to achieve the development of more accessible, efficient, equitable and universal tele-rehabilitation systems. This chapter presents a systematic literature review of summative and formative usability studies as well as accessibility studies in the context of tele-rehabilitation systems. The remaining of the manuscript is composed of four sections. Section 2 presents the method used to proceed with the systematic review. Section 3 is a description of the most relevant papers in usability applied to tele-rehabilitation. Section 4 describes the results regarding the accessibility. And Section 5 draws conclusions on the main findings of this literature review.[…]

 

Continue —> A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems | IntechOpen

Figure 1.
PRISMA 2009 flow diagram chart that shows the selection process of the papers included in the literature review for usability.

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[NEWS] Telemedicine-Delivered Arm Rehab Results on Par with In-Person Clinic

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Rehab muscle training for elbow joint

 

Post-stroke arm motor function recovery progressed just as well, whether the exercises were performed via home-based telemedicine or in an office environment, according to a randomized trial discussed recently at the International Stroke Conference.

Improvement in arm motor function on the Fugl-Meyer scale was 7.86 points with telerehab versus 8.36 points at day 30, which met noninferiority criteria, Steven Cramer, MD, of the University of California Irvine, reports, in a media release from Medpage Today.

Arm recovery exceeded the minimal clinically important difference in both groups and didn’t differ between rehab strategies by aphasia status.

“What we’re trying to do with home-based telehealth does not compete with or replace traditional rehab medicine. It is expanding tools,” Cramer adds.

ISC session moderator Louise McCullough, MD, PhD, of the University of Texas Health Science Center at Houston, agreed but noted some advantages to rehab from home.

“If we can optimize it… there could be huge cost savings,” she comments, “and especially for people in rural areas, like lots of Texas does not have access to rehab. It might be 2 hours away. This gives more options for people.”

The NIH StrokeNet trial included 124 adults who were 4 to 36 weeks post-ischemic or hemorrhagic stroke and had a baseline arm motor Fugl-Meyer score of 22 to 56 on the 66-point scale.

Treatment consisted of 36 sessions (18 supervised) of 70 minutes each, over 6 to 8 weeks. Intensity, duration, and frequency of therapy were matched between groups. Participants were randomized to therapy at home via telemedicine or in a traditional clinic setting with the same Accelerated Skill Acquisition program (impairment focused, task specific, and with intensive engagement), the release explains.

Telerehab patients started their supervised sessions with a video conference where they worked with the therapist.

For the 15 minutes of the session that was functional training, the in-clinic group got functional tasks whereas the home-based group got functional games. “This is not your father’s Wii game,” Cramer notes, in the release.

The games could be set to emphasize targets in specific parts of the visual field and could vary in speed, range of motion, target size, and cognitive demand. Input devices to play the games ranged from a squeezing device to a “whack-a-mole” mallet and a gun.

Patients’ preference to go to clinic appears to be because of that live social interaction. McCullough continues. “We now know social isolation is very common. But if you have low vision or you live alone, it’s really difficult to get to clinic. So now we have to get it so the preference is to do it at home.”

“I think that social interaction is going to be really important to fold into our telemedicine and telehealth platforms for whatever disease,” she adds.

[Source: Medpage Today]

 

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[WEB SITE] Study shows in-home therapy effective for stroke rehabilitation

stroke

A blood clot forming in the carotid artery. Credit: copyright American Heart Association

In-home rehabilitation, using a telehealth system and supervised by licensed occupational/physical therapists, is an effective means of improving arm motor status in stroke survivors, according to findings presented by University of California, Irvine neurologist Steven C. Cramer, MD, at the recent 2018 European Stroke Organisation Conference in Gothenburg, Sweden.

“Motor deficits are a major contributor to post-stroke disability, and we know that occupational and physical  improve patient outcomes in a supervised ,” said Cramer, a professor of neurology in the UCI School of Medicine. “Since many patients receive suboptimal therapy doses for reasons that include cost, availability, and difficulty with travel, we wanted to determine whether a comprehensive in-home telehealth therapy program could be as effective as in-clinic rehabilitation.”

In a study conducted at 11 U.S. sites, 124  underwent six weeks of intensive arm motor therapy, with half receiving traditional supervised in-clinic therapy and half undergoing an in-home rehabilitation program supervised via a videoconferenced telemedicine system.

Subjects were on average 61 years old, 4.5 months post-stroke, and had moderate arm motor deficits at study entry. When examined 30 days after the end of therapy, subjects in the in-clinic group improved by 8.4 points on the Fugl-Meyer scale, which measures arm motor status and ranges from 0 to 66, with higher numbers being better. Subjects in the telerehab group improved by 7.9 points, a difference that was not statistically significant.

“The current findings support the utility of a computer-based system in the home, used under the supervision of a licensed therapist, to provide clinically meaningful rehab therapy,” Cramer said. “Future applications might examine longer-term treatment, pair home-based telerehab with long-term dosing of a restorative drug, treat other neurological domains affected by stroke (such as language, memory, or gait), or expand the home treatment system to build out a smart home for stroke recovery.”

He said that the demand for rehabilitation services will likely increase, due to an aging population and increased stroke survival as a result of better access to advanced acute care. Telehealth, defined as the delivery of health-related services and information via telecommunication technologies, can potentially address this growing unmet need.

“We reasoned that telerehabilitation is ideally suited to efficiently provide a large dose of useful rehab therapy after stroke,” said Cramer, whose research team is part of the NIH StrokeNet consortium.

This research builds on the findings of a pilot study of 12 patients with late subacute  and arm-motor deficits who were provided 28 days of home-based telerehab program. The results, published in November 2017 in the journal Neurorehabilitation and Neural Repair, found that patient compliance was excellent (97.9%) and participants experienced significant arm-motor gains (Fugl-Meyer scale increase of 4.8 points). The study also found that patients did not need any additional computer skills training due to the design of the telerehab system.

“Getting patients to remain engaged and comply with therapy is a key measure of success of any rehabilitation program,” Cramer said. “Greater gains are associated with therapy that is challenging, motivating, accompanied by appropriate feedback, interesting and relevant. Telerehab achieves this because therapy is provided through games, provides user feedback, can be adjusted based on individual needs, is easy to use—and is fun.”

This study was supported by the Eunice Kennedy Shriver National Institute of Child Health & Human Development as well as the National Institute of Neurological Disorders and Stroke (grant U01 NS091951), the NIH StrokeNet Clinical Trials Network, the 11 US enrollment sites, the research team at the primary study site at the University of California, Irvine, and the patients and families who participated.

 

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[SHORT ARTICLE] Tele rehabilitation: two-year experience in conducting medical assessments via tele link

by Nalinda Andraweera, Consultant Physician in Rehabilitation Medicine,
Modbury Public Hospital, Adelaide, Australia.

Introduction

Telemedicine has been practised for many
decades since initial documentation in 1940s when
radiology images were sent between two townships
in Pennsylvania via telephone lines. Bioinstrumentation and transmission of astronauts’ vital parameters to ground based flight surgeons came to
forefront during NASA’s space programme in 1960s.
During following decades, telemedicine was used in
multiple medical specialties as a mode of patient
assessment. Use of telemedicine in Rehabilitation
Medicine is relatively recent. As multidisciplinary
coordinated care led by rehabilitation physicians and
allied clinicians is required, proformas are used in
tele rehabilitation assessments. Proformas help to
generate a clinical document with medical and allied
health assessments in one clinical record. Currently,
delivery of rehabilitation services is further empowered, enhanced and in evolution with the installation of dedicated software programmes for use by
allied health clinicians. Most units operating tele
medicine for rehabilitation medical services use
trained proctor with the client/patient to enable
more comprehensive examination to aid clinical
decision when the physician is stationed in a distant
site.

Evidence

Current evidence based on multi centre trials
suggest that well conducted tele rehabilitation enable
clinical outcomes similar to face to face rehabilitation.
Advantages of tele rehabilitation being low cost and
the ability to provide an increased volume of therapy
[1]. Drawbacks include limitations in detailed examination and negative implications in rehabilitation goal setting. If patients are reviewed early, frequent
and active communication is carried out during tele
rehabilitation, patient centred goal setting can be
improved [2].

Methodology

Client assessments were from a city Hospital in
Adelaide (Modbury Hospital) linked via a video link
to a regional general hospital (Riverland General
Hospital in Berri) 241 kilometres from Adelaide.
Period assessed is from May 2016 to September 2018.
Fortnightly tele ward rounds and additional initial
inpatient and outpatient assessments were conducted via a video link. Both inpatient and outpatientclients were informed and educated about method of
tele medicine and tele rehabilitation and consent was
obtained for video-based assessments with the
physician. A trained proctor was present at each
assessment.
Tele rehabilitation services were provided using
a secure, encrypted platform with privacy and
confidentiality maintained. Video link was established via a licenced communication provider enabling an uninterrupted video connection linking
patient and proctor with the physician. Electronic
transfer of clinical records was done using a secure
health email platform.
Trained proctor was a clinical nurse practitioner,
physiotherapist or an occupational therapist trained
to aid in clinical examinations required for musculoskeletal and neurological examination. Proformas were emailed to the physician prior to patient
assessment with medical history, current vital
parameters, medications and initial allied health
assessments. Video based clinical assessments were
recorded in a client proforma and a clinical report
was generated. Radiology and haematology/
biochemistry investigations were reviewed using a
medial investigation software used in South
Australian Health Service (Oasis). Urgent images
requested by the physician were done locally or at a
private service provider and snip tooled using a
licenced health imaging access pathway. Allied
health clinicians recorded initial functional levels
using FIM (Functional Independent Measure).
Following patient assessment, patient centred
realistic goals were discussed with the patient and
the multi-disciplinary team via video link.

Results

Assessments done from 18 May 2016 to 17
September 2018 were assessed. A total of 236 Tele
medicine assessments were completed for patients/
clients admitted for rehabilitation. Average duration
for an assessment was 26 minutes. Patient satisfaction
on telemedicine assessments was 100%.

Conclusion

Tele medical assessments of patients admitted
for rehabilitation is currently gaining momentum and
more health funding is allocated for further expansion
of tele medicine and tele rehabilitation. Carrying out
medical assessments via a licenced video linkage
allows clients/patients to be reviewed with minimal
delay, closer to their homes and without the need to
travel to a specialist centre in a city. Tele medical
assessments save time for physicians as no travel time
is required, objective assessments can be done
effectively with the help of a trained proctor. Assessment reports can be generated with minimal delay using proformas and electronically transferred to
local GPs and multidisciplinary rehabilitation team
members comprising physiotherapists, occupational
therapists, nurse practitioners, social workers and
nutritionists/dieticians. Tele medical assessments in
rehabilitation aid uninterrupted rehabilitation service
provision in a distant site. Patient satisfaction is high.

References

  1. O’Neil O, Fernandez MM, Herzog J, Beorchia M, Gower V,
    Gramatica F, et al. Virtual Reality for Neurorehabilitation:
    Insights From 3 European Clinics. PM R. 2018; 10(9S2):
    S198-S206.
  2. Plant SE, Tyson SF, Kirk S, Parsons J. What are the barriers
    and facilitators to goal-setting during rehabilitation for
    stroke and other acquired brain injuries? A systematic
    review and meta-synthesis. Clin Rehabil. 2016; 30(9):
    921-30.

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[Abstract] Efficiency in stroke management from acute care to rehabilitation: bedside versus telemedicine consultation

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BACKGROUND: Telemedicine has changed over the last years, becoming an integrated service used in various clinical settings such as stroke units or radiological departments, but also as an important tool for home rehabilitation. Assessment of usefulness and efficiency of performing teleconsultations to manage stroke from acute care hospital to tertiary care rehabilitation hospital has not been referred by scientific literature.
AIM: This article analyzes the process of discharging stroke patients from acute care to intensive rehabilitation, based on the comparison between conventional bedside patient evaluations and teleconsultation patient evaluations, to assess efficiency and efficacy of two different discharging workflows.
DESIGN: Retrospective study.
SETTING: Consultations were carried out between the Acute Care Stroke Unit (ACSU) and the Stroke Rehabilitation Unit (SRU) of Valduce Hospital System.
POPULATION: 257 stroke patients underwent physiatric consultation during 2 years considered in this study and 101 patients were considered eligible for intensive rehabilitation treatment after a physiatric consultation.
METHODS: we compared the efficiency and efficacy of the dismission workflow of bedside medical consultation and teleconsultation over a 12 months period. We considered the following outcome measures: time elapsed between consultation and rehabilitation unit admission, number of re-admissions to acute care hospital, complications occurred during rehabilitation, length of stay in the rehabilitation hospital and clinical outcomes of rehabilitation process.
RESULTS: we observed a significant reduction in waiting time from the acute event to the admission in rehabilitation department, an improvement in efficiency of the admission process itself in the rehabilitation unit and a reduction of clinical complications occurred during rehabilitation period, without changes in rehabilitative outcomes.
CONCLUSIONS: it has been highlighted that the use of telemedicine to perform medical consultation as a tool to evaluate patients eligible for tertiary care rehabilitation hospital admission from stroke care unit is feasible and more efficient when compared with conventional bedside consultations.
CLINICAL REHABILITATION IMPACT: this study reveals teleconsultations as a useful tool to improve efficiency of the stroke management workflow.

 

via Efficiency in stroke management from acute care to rehabilitation: bedside versus telemedicine consultation – European Journal of Physical and Rehabilitation Medicine 2018 Oct 29 – Minerva Medica – Journals

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[Abstract + References] The Transformation of the Rehabilitation Paradigm Across the Continuum of Care – PM&R

Abstract

As healthcare continues to evolve, there are changes in the delivery of care for patients with severe neurologic injuries. Although the acute hospital stay is shortening, physiatrists can play a key role in preparing patients for rehabilitation, minimizing longer-term complications and helping to determine the most appropriate paths for further treatment. Inpatient rehabilitation facilities (IRFs) continue to be an important part of the care continuum for patients with severe injuries, but the role of IRFs has also evolved as patients have been admitted with increasing medical and neurologic complexity and length of stay continues to be reduced. Skilled nursing facilities and subacute facilities continue to evolve, in part to fill the gaps that have developed for patients who are “not yet ready for rehabilitation” and for those whose recovery trajectory has been deemed too slow for IRF. Outpatient care is also changing, in part due to the availability of new rehabilitation interventions as highlighted in other sections of the supplement. Furthermore, telemedicine will provide additional options for expanding specialized care beyond prior geographical limitations. Physiatrists need to be aware of these ongoing changes and the roles that they can play outside of the traditional IRF model of care. This article will focus on the innovations in healthcare delivery and opportunities to maximize outcomes in the current and future models of care.

 

References

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  4. CMS adopts inpatient rehabilitation facility coverage requirements (2009, July 31). Available athttps://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2009-Fact-sheets-items/2009-07-314.html..

  5. Medical Payment Advisory Commission. MedPAC Report to Congress: Medicare Payment Policy, 2008..

  6. Medical Payment Advisory Commission. MedPAC Report to Congress: Post-Acute Care Reform, February 17, 2014..

  7. DaVanzo, J.E., El Gamil, A., Li, J.W., Shimer, M., Manolov, N., Dobson, A. Assessment of patient outcomes of rehabilitative care provided in inpatient rehabilitation facilities (IRFs) and after discharge. Final Report 13-127. Dobson, DaVanzo and Associates, LLCVienna, VA2014.
  8. Medicare Payment Advisory Commission (Report to the Congress). Medicare Payment Policy. July 2018..

  9. Medical Payment Advisory Commission. MedPAC Report to Congress: Medicare and the Health Care Delivery System, June 2014, 93-119..

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  11. Hammond, F.M., Horn, S.D., Smout, R.J. et al, Rehospitalization during 9 months after inpatient rehabilitation for traumatic brain injury. Arch Phys Med Rehabil2015;96:S330–S339.
  12. Guo, Y., Persyn, L., Palmer, J.L., Bruera, E. Incidence of and risk factors for transferring cancer patients from rehabilitation to acute care units. Am J Phys Med Rehabil2008;87:647–653.
  13. Truong, A.D., Fan, E., Brower, R.G., Needham, D.M. Bench-to-bedside review: mobilizing patients in the intensive care unit—from pathophysiology to clinical trials. Crit Care2009;13:216.
  14. Lord, R.K., Mayhew, C.R., Korupolu, R. et al, ICU early physical rehabilitation programs: financial modeling of cost savings. Crit Care Med2013;41:717–724.
  15. Giacino, J.T., Whyte, J., Bagiella, E. et al, Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med2012;366:819–826.
  16. Granger, C.V., Markello, S.J., Graham, J.E., Deutsch, A., Reistetter, T.A., Ottenbacher, K.J. The uniform data system for medical rehabilitation report of patients with traumatic brain injury discharged from rehabilitation programs in 2000–2007. Am J Phys Med Rehabil2010;89:265–278.
  17. National Spinal Cord Injury Statistical Center, Facts and Figures at a GlanceUniversity of Alabama at BirminghamBirmingham, AL2015.
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  19. Stefanacci, R.G. Admission criteria for facility-based post-acute services. Ann Long-Term Care Clin Care Aging2015;23:18–20.
  20. Alcusky, M., Ulbricht, C.M., Lapane, K.L. Post acute care setting, facility characteristics, and post stroke outcomes: A systematic review. Arch Phys Med Rehabil2018;99:1124–1140.
  21. Werner, R.M., Konetzka, R.T. Trends in post-acute care use among Medicare beneficiaries: 2000-2015. J Am Med Assoc2018;319:1616–1617.
  22. Xian, Y., Thomas, L., Liang, L. et al, Unexplained variation for hospitals’ use of inpatient rehabilitation and skilled nursing facilities after an acute ischemic stroke. Stroke2017;48:2836–2842.
  23. Stein, J., Bettger, J.P., Sicklick, A., Hedeman, R., Magdon-Ismail, Z., Schwamm, L.H. Use of a standardized assessment to predict rehabilitation care after acute stroke. Arch Phys Med Rehabil2015;96:210–217.
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  26. Piotrowicz, E., Baranowski, R., Bilinska, M. et al, A new model of home-based telemonitored cardiac rehabilitation in patients with heart failure: Effectiveness, quality of life, and adherence. Eur J Heart Fail2010;12:164–171.
  27. Dobkin, B.H., Dorsch, A.K. The evolution of personalized behavioral intervention technology: Will it change how we measure or deliver rehabilitation?. Stroke2017;48:2329–2334.
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  29. Chen, J., Jin, W., Zhang, X.X., Xu, W., Liu, X.N., Ren, C.C. Telerehabilitation approaches for stroke patients: Systematic review and meta-analysis of randomized controlled trials. J Stroke Cerebrovasc Dis2015;24:2660–2668.
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  34. Jagos, H., David, V., Haller, M. et al, A framework for (tele-) monitoring of the rehabilitation progress in stroke patients: eHealth 2015 special issue. Appl Clin Inform2015;6:757–768.
  35. Linder, S.M., Rosenfeldt, A.B., Bay, R.C., Sahu, K., Wolf, S.L., Alberts, J.L. Improving quality of life and depression after stroke through telerehabilitation. Am J Occup Ther2015;69:1–10.
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via The Transformation of the Rehabilitation Paradigm Across the Continuum of Care – PM&R

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[Poster] A Qualitative Study on a Telehealth System for Home-Based Stroke Rehabilitation

Abstract

Purpose: This abstract reports a qualitative study on a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education at the patient’s home. Therapists examine patients then establish regular videoconferences with them via the system to discuss their progress, provide feedback, and adjust treatment. The aims of this study were to investigate patients’ general impressions about the benefits of and barriers to using the telerehabilitation system at home.

Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 10 participants who had completed a 6-week intervention using the telerehabilitation system. Thematic analysis was conducted using the grounded theory approach.

Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions and provision of an outlet for mental tension and anxiety. They mainly valued the following four merits of the system: engaging game experience, flexibility in time and location in using the system, having the therapists accountable, and having less burden on caregivers. In particular, all participants rated highly their experience using the videoconference capability, which provided a channel for therapists to observe, correct, and provide feedback and encouragement to patients. Most patients expressed that they established a personal connection with the therapist through use of the telerehabilitation system. By doing so, they felt less isolated and more positive and connected. Finally, communicating with therapists three times a week also held patients accountable for completing the exercises. Barriers to system use were all logistics-related, such as the lack of physical space at home, which impeded effective use, and poor internet connection at home.

Conclusions: The telerehabilitation system studied provides patients with home-based access to games, exercises, education, and therapists. Based on participants’ qualitative feedback, it is a promising tool to deliver stroke rehabilitation therapies effectively and remotely to patients at home.

 

via Abstract TP154: A Qualitative Study on a Telehealth System for Home-Based Stroke Rehabilitation | Stroke

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[ARTICLE] A Cloud-Based Virtual Reality App for a Novel Telemindfulness Service: Rationale, Design and Feasibility Evaluation – Full Text

ABSTRACT

Background: Worldwide, there has been a marked increase in stress and anxiety, also among patients with traumatic brain injury (TBI). Access to psychology services is limited, with some estimates suggesting that over 50% of sufferers are not accessing the existing services available to them for reasons such as inconvenience, embarrassment, or stigmatization concerns around mental health. Health service providers have increasingly been turning to drug-free therapies, such as mindfulness programs, as complementary treatments.

Objective: Virtual reality (VR) as a new delivery method for meditation-based stress and anxiety reduction therapy offers configurable environments and privacy protection. Our objective was to design a serious learning-meditation environment and to test the feasibility of the developed telemindfulness approach based on cloud technologies.

Methods: We developed a cloud-based system, which consisted of a Web interface for the mindfulness instructor and remote clients, who had 3D VR headsets. The mindfulness instructor could communicate over the Web interface with the participants using the headset. Additionally, the Web app enabled group sessions in virtual rooms, 360-degree videos, and real interactions or standalone meditation. The mindfulness program was designed as an 8-week Mindfulness-Based Stress Reduction course specifically for the developed virtual environments. The program was tested with four employees and four patients with TBI. The effects were measured with psychometric tests, the Mindful Attention Awareness Scale (MAAS) and the Satisfaction With Life Scale (SWLS). Patients also carried out the Mini-Mental State Examination (MMSE). An additional objective evaluation has also been carried out by tracking head motion. Additionally, the power spectrum analyses of similar tasks between sessions were tested.

Results: The patients achieved a higher level of life satisfaction during the study (SWLS: mean 23.0, SD 1.8 vs mean 18.3, SD 3.9) and a slight increase of the MAAS score (mean 3.4, SD 0.6 vs mean 3.3, SD 0.4). Particular insight into the MAAS items revealed that one patient had a lower MAAS score (mean 2.3). Employees showed high MAAS scores (mean 4.3, SD 0.7) and although their SWLS dropped to mean 26, their SWLS was still high (mean 27.3, SD 2.8). The power spectrum showed that the employees had a considerable reduction in high-frequency movements less than 0.34 Hz, particularly with the 360-degree video. As expected, the patients demonstrated a gradual decrease of high-frequency movements while sitting during the mindfulness practices in the virtual environment.

Conclusions: With such a small sample size, it is too early to make any specific conclusions, but the presented results may accelerate the use of innovative technologies and challenge new ideas in research and development in the field of mindfulness/telemindfulness.

Introduction

Attention impairment has often been considered a hallmark of mental illness. Attention training is an important part of meditation, and has proven to augment the ability to sustain attention [1]. Mindfulness as a meditation tool has an important role in psychology, self-awareness, and well-being. The authors Brown and Ryan [2] reported that mindfulness over time was related to a reduction in variable mood and stress in patients with cancer. Mindfulness is an internationally recognized therapy that teaches self-awareness, maintaining own thoughts, sensations, feelings, emotions, and appreciation of your living environment [3]. The mindfulness meditation technique may help patients manage potentially negative outcomes and improve well-being by controlling unselfconsciousness (thoughts on failure). Avoiding problems associated with the future, focusing on the present, being “now,” and controlling the tracking of time may, in addition to well-being, lead to mindfulness. A person who can achieve such an active and open attention state can control thoughts from a distance, free to judge whether they are good or not [4]. In this context, mindfulness can also be considered an important tool for managing anxiety and stress in patients [2]. Kabat-Zinn [3] designed an 8-week meditation course, Mindfulness-Based Stress Reduction, which provides 2 hours of meditation in a group with additional homework. Mindfulness-Based Stress Reduction has demonstrated that awareness of the mind, unconscious thoughts, feelings, and other emotions positively affect major physiological processes and thus decreases the level of stress-related disorders [46].

Anxiety and stress disorders can be related to pressure at work, incurable diseases, or neuromuscular disorders, such as Parkinson disease, light traumatic brain injury (TBI), multiple sclerosis, or other diseases of the muscular or central nervous system. Deficits in executive functions, memory, and learning are often documented after TBI. In addition, at least half of those suffering from TBI experience chronic pain and/or sleep disorders, depression, and substance abuse [7].

A review of the literature shows that neural systems are modifiable networks and changes in the neural structure can occur in adults as a result of training [8]. The study reported on anatomical magnetic resonance imaging (MRI) images from 16 healthy meditation-naïve participants who underwent the 8-week mindfulness program [8]. The results obtained before and after the program suggested that participation in a Mindfulness-Based Stress Reduction course was associated with changes in gray matter concentration in the regions of the brain involved in learning and memory processes, emotion regulation, self-referential processing, and perspective taking.

Early rehabilitation in the acute and subacute phase may be a critical period and a key to effective rehabilitation, especially in TBI [9]. A significant drawback is that patients often stay in hospital for a limited time and are soon discharged for recovery at home. Afterward they can visit an outpatients’ clinic. Patients residing close may find the outpatient service convenient, but it could be very inconvenient for those who are in need of ongoing care, are dependent on public transport, or in the worst case do not have access to transport at all. Consequently, external factors such as travel fatigue may hinder the effectiveness of the therapy and, in some, may even increase anxiety and stress. In addition, modern diseases caused by stress and anxiety in the workplace are on the increase, but access to treatment and therapy is usually not possible during working hours [10].

Innovative technologies can ensure real-time communication and data recording/sharing over long distances, even within larger groups of participants [11]. Nowadays, privacy, data security, shyness, and pride are among the most frequent reasons to avoid therapy if a mental disease or neuromuscular disorder is related to work or social status [12].

Some patients prefer to remain anonymous and do not want to reveal their problems, even to colleagues. The sense of “total immersion” created by virtual reality (VR) is an emerging technology that may entirely replace mainstream videoconferencing techniques [13]. These technologies may fulfill patient expectations [14] regarding anonymity and enhance presence [15]. Patients can hide their identify using an avatar and their voices can be disguised. Psychologists and other experts may observe the kinematic changes in motion patterns, gestures, face mimics, and other measurable features [12]. If there is a group, the VR avatars can be synchronized and controlled in real time, using cloud-based technologies. The operator can form groups, deliver individual or group tasks, or lead a private conversation with selected participants. We have developed a technology that is available for home and workplace use, called Realizing Collaborative Virtual Reality for Well-being and Self-Healing (ReCoVR), for which the VR headset is coupled with a mobile phone. The only requirement is a connection to Wi-Fi/4G Internet, plus communication with the cloud server allows remote interaction with other users residing thousands of miles away.

This cloud-based app is used for interaction and communication between a mindfulness expert and participants. Each participant uses a commercially available mobile phone and a simple head-mounted VR headset to join the mindfulness session in the virtual environment (VE). Our main objectives were to design a suitable mindfulness protocol based on Mindfulness-Based Stress Reduction, with tasks in the VE with 360-degree videos, and to test the feasibility of the developed mindfulness/telemindfulness app in a real environment. Additionally, we analyzed head movements during mindfulness sessions to stimulate further initiatives in this research space. […]

Continue —> JRP-A Cloud-Based Virtual Reality App for a Novel Telemindfulness Service: Rationale, Design and Feasibility Evaluation | Cikajlo | JMIR Research Protocols

Figure 1. The ReCoVR system consists of a cloud server, serving information for the WebGL scenery and synchronization of the data (audio, video, data) between the server and clients. The clients connect to the server as mindfulness experts (using a computer with Web browser) and as mindfulness therapy participants (using Samsung GearVR 3D headset with Wi-Fi/LTE).

Figure 2. The mindfulness instructor uses the Web interface to manage the group therapy in the virtual room. The Web interface enables video-audio communication with the participants (below left), making subgroups, and assigning tasks (right) for mindfulness sessions. Additionally, the therapist can share documents and lead the session, while everybody can send/receive messages and talk to other group members.

 

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