Computer Assisted REhabilitation (CARE) Lab: A novel approach towards Pediatric Rehabilitation 2.0

1. Introduction

Pediatric rehabilitation (PR) focuses on children along their different phases of growth, and thus it has to take into account their stage of development and emerging needs. PR primary goal is the improvement of impaired abilities (and sometimes recovering those that have been lost), with the ultimate aim of providing individualized opportunities for “full and effective participation and inclusion in society” [1]. This process should not be confined to rehabilitation centers but transition gradually into the children’s everyday life, involving their caregivers, teachers, relatives and friends [2].

Pediatric rehabilitation therapists have always worked using a variety of off-the-shelf or specially designed objects and devices which have increasingly come to include computer solutions to train specific abilities. The appeal of easy-to-use, interactive videogame consoles based on detecting actual users’ movements rather than pressing keys, has led a number of therapists to include them in their rehabilitation protocols. A proof of this evolution can be the recent introduction of the neologism Wiihabilitation, which derives from the use of Nintendo’s Wii console (Nintendo, Kyoto, Japan) for rehabilitation activities [3]. Using commercially available consoles has many advantages (appeal, cost, and ease of use by therapists and patients), and although recent reviews indicate lack of large-scale studies and randomised controlled trials [4, 5], there is an increasing evidence of their positive effects [6, 7].

However, these consoles are designed for the entertainment of average young people with normal abilities, and they have some limitations when used for rehabilitation purposes. First of all, they are usually not tailored to children with motor or cognitive impairments [8], as the videogames they run cannot be adapted to the specific needs and abilities of impaired children [8, 9], and also because each console relies on its specific controllers (i.e. Nintendo WiiMote and Balance Board, Sony EyeToy, Microsoft Kinect). Moreover, as the goal of videogame players is to maximize the score, we speculate that impaired children may use compensatory movements and postures that could negatively affect the rehabilitation process. Thirdly, the measurements acquired by the sensing devices are sealed into the systems, and cannot be transferred and used elsewhere to assess rehabilitation progress.

Another approach has seen the development of more sophisticated Information and Communication Technologies (ICT) solutions specifically designed for rehabilitation [8, 10, 11]. These are often expensive and difficult to use, and their poor and not-so-challenging multimedia content makes them less appealing to children than traditional videogames.

Finally, although a number of architectures have recently been developed as commercial products/services (i.e. Neuro@home [12], VirtualRehab, etc.), or for research purposes (i.e. Rewire [13], Riablo [14] and Rehab@home [15], etc.), they do not seem to be particularly suitable for PR. Thus their routine use sometimes requires specific technical skills.

The term Web 2.0 refers to the current revolution in Internet technology. The contents of the original World Wide Web (Web 1.0) were defined a priori and presented to users in a fixed and unchangeable manner, whereas Web 2.0 is based on new interactive architectures that have opened the way to a number of interactive services, including the “social networks”. Knight et al. [16] suggested using the name “Physical Therapy 2.0” to describe the innovative approach that combines traditional rehabilitation principles and the use of specifically designed ICT solutions. Hence, we propose the term “Pediatric Rehabilitation 2.0”, where the main difference from the traditional approach is that computers play a key role in the rehabilitation process, thus extending their use beyond usual training software programs (i.e. cognitive training [17]) or the simple use of videogame consoles [6]. This may be accomplished by exploiting the interactivity and engagement of videogames as key factors to sustain a greater involvement of children, while increasing treatment efficacy.

Generally speaking, the computer-assisted approach is gaining widespread interest and popularity in the rehabilitation field due to the wide-spread diffusion of mobile and computer-based devices. However, since there is still a lack of strong evidence of its efficacy, due to the heterogeneity and small sample size of the available studies, it is important to address the issue appropriately, with the aim of bridging the gap between research efforts and clinical practice.

There is a real need to design solutions that can become a routine part of PR, while avoiding the pitfalls of misusing technology by becoming either “technology-driven” or “technology-reluctant”. To cope with this challenge which requires the appropriate balance of new technologies and PR principles, we created a Computer-Assisted REhabilitation (CARE) Lab, a place where to study innovative approaches, we referred to as “Pediatric Rehabilitation 2.0”. Thus, the aim of this paper is to describe the process that led us to design, build and start using this lab, and the keywords that guided us in this journey.

2. Methodology and procedure

In this section, the two main methodological issues related to the novel “Pediatric Rehabilitation 2.0” approach will be described as follows: 1) the theoretical framework and 2) the operative steps. These issues derived from our previous experience using an advanced ICT system (VRRS, from Khymeya, Padua, Italy) that, despite very interesting albeit preliminary results [10], revealed intrinsic limitations with respect to the broad spectrum of rehabilitation needs of children admitted to the Neuropsychiatric and Rehabilitation Unit. After a survey of the commercially available solutions, we realized there was a need to build a place specifically designed for a computer-assisted rehabilitation, by I) developing a suitable software architecture to support a variety of exercises, II) using various types of sensors and III) offering the possibility (in perspective) to provide multiple and differentiated feedback to the treated children.

A pilot study on subjects aged 7–14 years with congenital hemiparesis is currently ongoing. The rehabilitation protocol consists of ten weekly sessions, with rehabilitation games specifically designed and developed to improve frontal and lateral reaching with the paretic upper limb and other exercises for pronation-supination and tracking movements.

Figure 6 shows an example plot of the trajectory of a child’s involved hand during a simple exercise of moving a virtual hand with the aim of bursting all the virtual bubbles that appear on the screen.

Preliminary results regarding a small group of six subjects show: an overall increase in MA2 scores, especially the median improvement in “movement range” (from 61.1% to 81.1%), “dexterity” (from 52.6% to 65.8%), “fluency” (from 52.4% to 62%), and “precision” (from 92% to 96%); an increase in passive and active ROM, with mean passive and active shoulder flexion respectively improving from 151.2 ∘ to 161.7 ∘ and from 144.2 ∘ to 152.3 ∘ , mean passive and active shoulder extension respectively improving from 36.7 ∘ to 42.5 ∘ and from 29.2 ∘ to 33.7 ∘ ; and an overall increase in upper limb motor performance as revealed by the ABILHAND-Kids questionnaire. Furthermore the parents of four of the children reported improvements in “Zipping up a jacket”, “Putting on a backpack”, and “Washing the upper body”.

Although these are only preliminary results from a very small sample of children, they are encouraging at both functional and assessment levels, and also in terms of the activities of daily life (ADL). They are even more interesting bearing in mind that they were obtained after a small number of weekly sessions carried out over a limited period of time (2–3 months).

4. Discussion and conclusion

We are in the middle of a scientific, clinical and social transformation driven by the pervasive spread of ICT devices and systems (smartphones, tablets, wearables, etc.), the effects of which will also profoundly influence the entire approach to rehabilitation. These solutions may not only affect traditional rehabilitation techniques, but could also lead to a new and intrinsically quantitative PR paradigm based on increased inner motivation and patient engagement.

Pediatric Rehabilitation 2.0 is thus characterized, in our opinion, by its transition from the usual three-step approach (pre-intervention assessments, rehabilitation, and post-intervention assessments) to a more continuous one in which the data collected during the rehabilitation process can be used continuously to assess and adapt the process itself.

This paper briefly describes some important theoretical aspects and the experience so far gained in the field, which we have summarized in the acronym EPIQ (Ecological, Personalized, Interactive, and Quantitative). Thanks to this experience which has highlighted both the complexity and the potentialities of this new approach, we are conscious of being at the beginning of a new journey that will require a number of open questions to be addressed and, possibly, answered.

For a thorough evaluation of the computer-assisted approach’s efficacy it is necessary to clarify how much of the rehabilitation work carried out in a virtual or artificial environment can support the real transfer of newly learned skills to ADL. Moreover, it should be carefully assessed for how long, whether and to what extent the “smartification” of objects (i.e. transforming usual objects into connected and interactive ones) and/or the surrounding environment can contribute to facilitate such a transfer.

Like the recent literature [4], these considerations underline the increasing need for further and larger studies of the ways in which the increasingly pervasive presence of technology is likely to reshape PR in the near future.