ebavir, easy Balance Virtual Rehabilitation system: a study with patients
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1 ebavir, easy Balance Virtual Rehabilitation system: a study with patients M. González-Fernández 1, José-Antonio Gil-Gómez 1, M. Alcañiz 1, E. Noé 2, C. Colomer 2 1 Instituto Interuniversitario de Investigación en Bioingeniería y Tecnología Orientada al Ser Humano, Universidad Politécnica de Valencia, Valencia (España) 2 Servicio de Daño Cerebral NISA; Fund. Inst. Valenciano Neurorrehab. (FIVAN) Abstract. ebavir is a virtual rehabilitation system, which has been developed for balance rehabilitation for patients suffering from acquired brain injury. It is a game-based system that uses a low-cost interface, the Nintendo Wii Balance Board. The games have been specifically designed with the help of experts in the rehabilitation of balance disorders and can be adapted to patients according to their needs. We present an experimental study that has been carried out using the system. The aim of the study is to determine whether this setup could be applied as a Virtual Rehabilitation System for balance rehabilitation in Acquired Brain Injury. We randomly divided patients into two groups: a trial group and a control group. The trial group used ebavir system during the rehabilitation sessions, and the control group followed traditional rehabilitation sessions. We obtained encouraging results. Keywords. Virtual Rehabilitation Therapy, Wii Balance Board, Stroke, Balance Introduction The causes of Acquired Brain Injury (ABI) may be multiple, such as Traumatic Brain Injury (TBI) or stroke. Its consequences are disabling and complex, resulting in motor, sensory and neuro-cognitive problems for the patients, which entails the loss of functional independence. In order to maximize the independence of people with ABI, a rehabilitation process that requires the treatment of physical, psychological and cognitive problems is carried out. In patients with neurological damage of the central nervous system, postural disorders represent one of the most significant disabilities, and many patients do not recover the ability to maintain an upright stance [1]. Among other biological and functional characteristics, postural control could be the best indicator of independent living. The recovery of postural control by the patient can be considered to be essential for independent living, as well as for social participation and general health. Thus, balance training is a critical therapeutic procedure for walking and training patients to care for themselves [2]. The use of virtual reality techniques and the latest innovations in technology can be of great assistance when applied to rehabilitation procedures [3]. The benefits of rehabilitation following ABI are all too often disrupted by a lack of patient engagement in the process [4]. One of the advantages of virtual reality systems is that they increase
2 the motivation of the patient, thereby improving continuity, which has an impact on recovery. In this paper, we present the results of a clinical trial for evaluating a low cost virtual rehabilitation system. The development of the system and subsequent clinical study were carried out jointly by LabHuman from the Universidad Politécnica de Valencia and Nisa Valencia al Mar Hospital, both located in Valencia (Spain). 1. Methods 1.1. System Description The ebavir system is a game-based system that uses a low-cost interface device, the Nintendo Wii Balance Board. The system hardware components are a conventional PC, a 42 LCD Screen and a Nintendo Wii Balance Board (WBB). The Nintendo WBB is composed of four pressure sensors located in its vertices. These sensors allow it to detect the pressure distribution on the board. Therefore, a profile of the balance motion can be achieved by measuring the weight distribution in each of the sensors over time. A wireless communication between the PC and the Wii Balance Board is established via Bluetooth. The balance board also has the advantage of being portable, easy and comfortable to handle, thanks to its small size and weight. The software system is composed of three. These games have been specifically developed with the help of experts in the field of rehabilitation of balance disorders. The games are designed to improve the static balance rehabilitation of the patients. These games are simple and have targets and modes that can be easily understood by the ABI patient. All these games require the transfer of body weight while maintaining standing balance. These weight displacements are part of the conventional rehabilitation procedures of ABI patients. The patient stands on the balance board and performs movements on both the sagittal and frontal planes, while attempting to control the game target element that appears on the screen. All the games have an initial configuration interface. This initial screen allows the physiotherapist to parameterize the game to suit the needs of each patient. There are two sets of parameters: a set that configures the rehabilitation session, such as the length of the session and the number of breaks per session; and a set that configures the game level with parameters such as the size or the speed of the game elements. ABI patients frequently have hemiparesis. One of the most characteristic consequences of incomplete recovery from hemiparesis is that there is a weight-bearing asymmetry in favour of the non paretic leg as well as increased spontaneous postural sway[5][6]. Because of this, the next step after configuration is to automatically adjust the sensitivity of the WBB to each patient s limitations. The system is designed to record the resting position of the patient and his/her range of motion in both the frontal and sagittal planes, which adapts the game environment to the patient s movement. Once the rehabilitation session and the game have been configured and the platform automatically adjusts itself, it is time to begin the rehabilitation session. During this session, the system gives the patient auditory feedback with a negative sound when the patient perform an incorrect action and a positive sound when the patient accomplish his/her goal throughout sessions. The patient score is continuously displayed and points are accumulated to calculate a final score. At the end of the
3 rehabilitation session, the system shows the patient percentage of hits and errors made during the game. Game results and sounds serve as a motivational element Protocol The clinical trial was carried out in the facilities of the Valencia al Mar Hospital, which is located in the city of Valencia (Spain). It was developed by a team of neurologists and physiotherapists from the Brain Injury Service of the Hospital. A sample of twenty patients from those under treatment at the Brain Injury Service was selected. The participants were randomly divided into a control group and a trial group. Our evaluation consisted of a comparison of these two groups. Each subject participated in a total of 20 rehabilitation sessions. Their balance was evaluated using the following quantitative measures: ordinal scales, timed scales and a feedback questionnaire filled out by the patients. These measures were collected right before the first rehabilitation session (T0); at the end of the last rehabilitation session (T20); and twenty days after the last rehabilitation session(t20+20) Subjects All the participants were patients with ABI, causing hemicorporal weakness and without the cerebellum-trunk structure being affected. Most of the patients diagnoses were either isquemic stroke or hemorrhagic stroke. However, three of the patients suffered from TBI, and three suffered from other types of ABI. At the beginning of the study, all the patients had been affected by ABI for over eight months. The patients ranged in age from 15 to 76 years old. Of the total, 64.7% of the participants were men, and 35.3% were women. According to the Berg scale, at the beginning of the study, ten patients had a risk of falling and ten had no risk of falling. In addition, all the participants had a normal cognitive function and were able to walk 10 meters indoors with or without technical orthopedic aids. None of the participants had had previous experience with virtual rehabilitation therapies. 2. Results Until now, five patients from the control group and five patients from de trial group have completed the rehabilitation process. We analyzed the results obtained according to the Berg Scale using repeated measures ANOVA. Patients were assessed at the beginning and end of treatment. A post-evaluation after 20 days is currently underway, and we will include the results in future works. Table 1 shows the inter-subject results. The results show that there was no significant difference between the participants in the two groups (p = 0.393). Table 1. Inter-subject effects. Source Sq Sum tipoiii gl Mean sq F Sig Intersection Group Error
4 Table 2 shows the intra-subject results. factor1 refers to the Start or End of the treatment and Group refers to Control or Trial group. These results show that there were significant difference when comparing Berg scores obtained by the patients before and after treatment, regardless of the groups that they were assigned to (p = 0.002). The intra-subject results also indicates that both, factor1 and Group had a statistically significant influence on the patients scores (p = 0.020). Patients from different groups have different evolution over time. Table 2. Intra-subject effects. Source Factor1 Sq Sum tipoiii gl Mean sq F Sig factor1 Lineal factor1*group Lineal Error(factor1) Lineal Figure 1 shows the evolution of each group according to the Berg Scale. The trial group had a better evolution than the control group. Figure 1. The graphic shows the evolution of the control and trial groups according to Berg Scale All other tests used show no significant difference in the evolution of the groups. The feedback questionnaire filled out by the patients of the trial group, shows influence of the system in patient motivation, since they declared to have enjoyed during rehabilitation sessions. In addition, patients thought the treatment was very useful for their rehabilitation. 3. Discussion and Conclusions Among the factors that influence the total costs of a virtual rehabilitation system, an important one is the tracking system that is used. The system that we present has the advantage of being an inexpensive system, thanks to the interface used (WBB) which decreases the total cost of the system. Even though ebavir is not immersive, we consider that an immersive environment is not necessary for the purpose for which it
5 was designed. Moreover, this might even be an advantage because the system does not require a high performance visualization system, and therefore, the cost is lower. Also, thanks to the characteristics of the Wii Balance Board (its small size and its light weight), the system does not require large spaces for installation an use, nor special environmental conditions as might be necessary with other tracking systems. This makes it a fully mobile interface that is easy to install in a clinical environment, since it does not require a large area for use or storage. These characteristics make ebavir a low-cost system that is easily adaptable to rehabilitation centres, also easily extended to patients homes, and can even be part of a tele-rehabilitation system. The results obtained in the clinical study show significant improvement of static balance in patients trained with the ebavir system over the control group. However, there was no difference in the dynamic balance tests between the trial group and the control group. In this study we worked with patients who had chronic brain damage for over eight months. Since their evolution is slower than recently injured patients, and taking into account the duration of the study (20 sessions), a longer study would be desirable in order to obtain further information on the evolution of both groups. Also, the results of this evaluation should be verified with a post evaluation after 20 days. This post-evaluation is currently underway. Another point that must be studied further is whether the use of ebavir system would improve the dynamic balance of patients when executing more dynamic exercises than those already tested. Furthermore, physiotherapists have shown a great interest in testing the system for improving static equilibrium in earlier stages of rehabilitation. Acknowledgement The authors wish to thank the staff and patients of the Servicio de Daño Cerebral from the Hospital Valencia al Mar for their time and great interest. References [1] Nicolas Genthon, Phd; Patrice Rougier, PhD, Anne-Sophie Gissot, PhD; Jérôme Froger, MD; Jacques Pelissier, MD; Dominic Pérennou, MD,PhD. Contributions of each lower limb to upright standing in stroke patients. Stroke by American Heart Association (2008) [2] M. Y. Lee, M. K. Wong and F. T. Tang. Clinical evaluation of a new biofeedback standing balance. Journal of Medical Engineering & Technology, Vol 20, Nº 2, (1996) [3] G. Burdea. "Keynote Address: Virtual Rehabilitation: Benefits and Challenges". 1st Int. Workshop on Virtual Reality Rehabilitation (2002) 1-11 [4] A.R. Medley, T. Powell. Motivational Interviewing to promote self-awareness and engagement in rehabilitation following acquired brain injury: A conceptual review. Neuropsychological rehabilitation. (2010) 1-28 [5] Alexander C.H Geurts, Mirjam de Haart, I.J van Nes, Jaak Duysen. A review of standing balance recovery from stroke. Gait & Posture 22 (2005) [6] D. Pérennou. Weight bearing asymmetry in standing hemiparetic patients. Journal of neurology, neurosurgery, and psychiatry. (2005) 76(5)
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