The emerging role of Microsoft Kinect in physiotherapy rehabilitation for stroke patients

Original Editor - Karen Feeney, Kate Reidy, Nicole Bell, Sally Wood and Joanne Knowles as part of the "Current and Emerging Roles in Physiotherapy Practice" QMU Current and Emerging Roles in Physiotherapy Practice Project. 

Top Contributors -Karen Feeney, Sally Wood, Nicole Bell, Kate Reidy, Joanne Knowles   

 Introduction:Where it all began

1.0 Introduction

The median age of the general population is predicted to significantly rise in upcoming years. This causes much added stress for clinics and hospitals. Stroke is a significant risk factor with age and the need for new rehabilitation is in demand. Technology and its advanced methods are continuously being assessed so that they can be used in a private, home-based setting while still providing rehabilitation instructions and progress tracking. This area of rehabilitation technology is expected to expand and will do so over the current year's 

Virtual Reality, is a clinically validated physical rehabilitation resource based on video games and motion capture technology. It was developed to treat patients suffering from various conditions and pathologies for example neurodegenerative disease such as Multiple Sclerosis (MS) and Parkinson's disease (PD), neuromuscular disorders such as dystrophies and myopathies, and neurovascular disorders and trauma such as stroke and traumatic brain injuries.

Virtual Rehab was developed in 2012 to test out the possibilities of using video games as a potential rehabilitation tool. The Kinect allows the patient to interact with the system in a 3D environment, where they perform multiple movement combinations without the need of an attached device or a controller

VirtualRehab is tackling major issues related to rehabilitation. Not only is it providing a rehabilitation service which improves adherence to treatment by adding fun and entertaining features, but it also reduces the high cost associated with traditional rehabilitation making it more affordable and accessible to everyone.

Ideally, all stroke rehabilitation exercises would be performed with a therapist in a clinical setting on a daily basis with a recommended session of 45min per patient. However, this demand within hospitals is becoming increasing difficult and logistically impractical.

Microsoft Kinect is the forerunner in commercially available hardware in which development of these new technologies can be built. Information on how it works, what is does, and an insight into Virtual Rehab developed by Microsoft Kinect for the use of stroke patients will be discussed in the following physiopaedia page.

Key words: Microsoft Kinect, virtual rehab, rehabilitation, and stroke. 

 

Audience

The resource is designed to provide at students and recently qualified physiotherapists with an insight into Microsoft Kinect and its use in stroke rehabilitation. However, this should not be exclusive as other healthcare professionals, or individuals with an interest in the topic may extract relevant and useful information to the potential use of Microsoft Kinect.

Learning outcomes 

By the end the reader will be able to:

• Identify and justify the knowledge and reasoning behind the use of Microsoft Kinect in physiotherapy practice for the rehabilitation of stroke patients.
• Critically evaluate the evidence behind Microsoft Kinect in the rehabilitation of stroke patients. 
• Justify the use of Microsoft Kinect and how this benefits patient outcomes.
• Outline the key knowledge and skills physiotherapists will require in order to provide effective rehabilitation programmes using Microsoft Kinect in the rehabilitation of stroke patients in the future. 

What is Microsoft Kinect 

Kinect derived from the meaning of the word kinetic (meaning to produce movement).

Microsoft's Kinect is described as a "controller-free gaming and entertainment experience" and is commonly sold bundled with the Xbox 360. However, to see it as only a way to play games would underestimate its significance and brilliance.

A computer based gaming systems such as Microsoft Kinect (Kinect), can facilitate complex task practice, enhance sensory and motor feedback, and provide visually observed technique for the user.

The Kinect is currently the hardware that provides developers with the greatest opportunities for innovative programs - for both games and applications.

Essentially this hardware is a box with some cameras that makes use of infra-red (IR) illumination to obtain depth data, colour images and sound. The Kinect system can identify players through face and voice recognition. Kinect can "see" in 3-D and creates a skeleton image of the player and a motion sensor detects movement.

Demands placed on physiotherapy rehabilitation services 

Stroke occurs approximately 152,000 times a year in the UK; that is one every 3 minutes 27 seconds. As people are living longer the number of sufferers will continue to increase, making cost effective community rehabilitation a higher priority. Stroke is the largest cause of complex disability with half of stroke survivors being left with residual disability . Globally the challenge of providing quality, affordable health care has never been so fundamental in stroke rehabilitation. The number of sessions that stroke survivors attend is restricted to the availability of a clinic near their residence and the amount of time friends and family can offer to help them commute, as most are incompetent of driving. With the high prevalence rate of stroke this puts increased demand on physiotherapists to treat each patient both in hospital and after discharge.

Although many people with stroke receive early rehabilitation, many are left dissatisfied with the way they are followed up and the level of rehabilitation provided in the year following the stroke . Due to time restraints and prioritisation of patients they can be pushed further down the rehabilitation follow up list. Another challenge to effective rehabilitation is insufficient completion of rehabilitation exercises by patients which severely reduces the potential outcome of overall motor recovery. Exercises are often unpleasant and tedious leading to patient's tolerance for exercise to decline . Patients are often dependent on one-to-one rehabilitation services provided by physiotherapists to help regain their functional ability. It is widely recognised that a strong rehabilitation serviceusing technologically advanced methods is the most effective and efficient way of addressing these growing issues .Rehabilitation in the home is more flexible and convenient for the patient and allows more frequent repetition of exercises. In order to stimulate neural reactivation in the regions of the brain that controls movement, exercises must be repeated many times every day. While rehabilitation sessions alone often cannot fulfil the required frequency of practice, at home rehabilitation programmes using Microsoft Kinect can help achieve this goal.

                                                                                                                                                                           

How Microsoft kinect can help

Microsoft kinect can: :

• Provide flexibility in delivering individualised physiotherapy in the patient's home.
• Involve carers more within the rehabilitative process.
• Help the NHS meet National Clinical Guidelines on physiotherapy interventions for stroke suffers (45 minutes per day of treatment during the acute phase) 
• Improve patient engagement through stimulating rehabilitation.
• Be a low cost rehabilitation tool.
• Reduce the need for expensive one-to-one clinical contact.
• Provide a range of indirect savings due to improved rehabilitation of patient.
  

Question Time

1.   Name three ways in which Microsoft Kinect can help in the rehabilitation of stroke patients

2.   What are the main contributing factors which may increase demands on the healthcare system at present?

3.   What is the recommended daily treatment time for patients in the acute phase of stroke rehabilitation?

Stroke and the need for intensive rehabilitation

Physiotherapy plays a key role in the rehabilitation of those affected by stroke and is needed in order to aid patients through their journey of recovery. Physiotherapy in stroke rehabilitation typically aims to strengthen and retrain muscles to regain lost limb function and improve quality of life.

Through studies of motor learning and motor control evidence shows that for effective learning and muscle re-education to take place practice of exercises needs to be intensive and frequent . The most rapid recovery occurs within the first 3 months post stroke and therefore during this time frame patients need intensive rehabilitation therapy. Unfortunately, currently in most NHS hospitals stroke patients receive approximately 7.5hours of physiotherapy rehabilitation per week and when discharged patients receive on average 1-2 hours of community rehabilitation per week. Additionally, the current Early supported discharge (ESD) plan, for stroke patients with mild to moderate disability, only runs for on average 6 weeks . Due to the current economic status of the NHS this is not likely to improve therefore more intensive rehabilitation strategies need to be introduced in order to improve outcomes for stroke patients.

Patients are being discharged from hospital earlier and earlier as there is a need to free up hospital beds which often leaves patients with fewer hours of physiotherapy rehabilitation. There is therefore a need for cost effective, intensive home based physiotherapy programmes which retrain and re-educate muscles in stroke patients.

Is Microsoft Kinect the answer?

Microsoft Kinect allows intensive stroke rehabilitation to take place in the home environment as well as taking pressure off health providers as patients can perform this type of rehabilitation on there own.

Stroke and Microsoft Kinect: Background

The demand for technologically advanced home-based rehabilitation which allows therapists to track progression is expected to expand. Microsoft Kinect is the leading commercially available hardware which can be developed to meet these needs while simultaneously maintaining affordability.

In an ideal world, stroke rehabilitation would take place with one to one therapist-patient interaction on a daily basis, however, as mentioned previously the demands on both the NHS and physiotherapists makes this dream difficult to achieve. Through guided interactive rehabilitation and the ability for therapists to track progress, the Kinect-based stroke rehabilitation programmes potentially reduce these difficulties on demand. The accuracy of the Kinect for clinical use in stroke rehabilitation is strong, allowing therapist assisted home-based rehab to become a reality. The Kinects ability to allow therapists to track progress and give feedback may not only enhance rehabilitation, but also improve medical record keeping .

Some useful statistics as well as facts and current care pathway information can be found here:
<a href="https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf">www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf</a>

Question Time:

1.   Using the Stroke Association link above find out how many hospital beds on average are taken up by stroke patients

2.   Using the Stroke Association link above find out what percentage hospitals have access to ESD service

      a.What do you think the implications of this are?

                                           b.How do you think microsoft kinect could help?

Microsoft Kinect

What is Microsoft Kinect?

Microsoft Kinect is a recently advanced multimedia console that was created to revolutionise the gaming experience and the way people experience entertainment. Sensors are used with the device which can directly sense a players’ movement and their environment. The sensors used with this device utilise 3D depth cameras which enables people to interact with games using their own body in a natural way . A unique characteristic of this console is that the games are played without the use of a controller as whole limb movements are monitored by the sensor. The impact the Kinect has made has ventured far beyond the gaming industry and has extended into creating new and exciting ways to interact such as helping doctors in operating rooms, helping children with autism and rehabilitating neurological patients. A team at Southampton have taken this technology to the next level and created an algorithm whereby the Microsoft Kinect sensors can track and measure joint angles of the hand and fine dexterity of individual finger movements making movements recorded even more precise .

Kinect is a bar measuring 14.8” x 5.9” x 4.8” and weighing about 3 pounds which is normally placed underneath or above the screen it is being used on. Several versions have been created for use with Xbox game consoles and Windows PC, although the latter has been discontinued as Microsoft wanted to stick with one single sensor to create consistency. However a PC adapter can be used with the Xbox One version so that it can still be used with a Windows computer. The Kinect consists of a RGB camera, a depth sensor and a multiarray microphone providing full body 3D motion capture, facial recognition and voice recognition capabilities (see figure below) . The RGB camera allows the Kinect to recognise up to 6 people and up to two people can be tracked. Skeletal tracking allows users to be tracked whilst sitting or standing and facing the Kinect. The user simply has to stand in front of the Kinect with head and upper limbs visible to be recognised, no specific calibrations need to be made for a user to be tracked. Skeletal tracking mode allows the sensor to track 20 joint coordinates in 3D space per player (Microsoft, 2015). Users are provided with a NUI (natural user interface) which allows them to control the game with a gesture or voice command. The ability of the Kinect to capture 3D data independent of lighting conditions strengthens the value of the console in rehabilitation settings.

Many different companies and organisations have utilised the unique technology of the Microsoft Kinect to create rehabilitation based software programmes. Creating new and innovative rehabilitation options for many different groups of patients but most notably those with neurological conditions such as stroke, Parkinson’s disease and Multiple Sclerosis. Two currently developing softwares for the rehabilitation of neurological conditions that we will explore further are VirtualRehab and Jintronix.

The software programmes can be used in clinic and in patients’ homes where they can continue their rehabilitation programmes. Due to the games being more engaging, interesting and innovative, they have the ability to create improved motivation and compliance leading to better patient outcomes. Motivation is improved as patients can work against themselves and see improvements no matter how small. Compliance is maintained due to the more exciting nature of the games making patients more likely to rehabilitate everyday as maintaining a set routine of exercise for weeks on end can become tedious.

VirtualRehab

VirtualRehab is a clinically validated physical rehabilitation system which uses videogame and motion sensor technology to deliver rehabilitation. It is the very first virtual rehabilitation software to be classified as a medical device donning the CE mark of approval with regulatory system of EU’s Medical Device Directives. The software product has been developed by a multidisciplinary team of experts in neurology and physiotherapy. This software enables patients with different affected functions to work on rehabilitation in an innovative and exciting way. It allows for the treatment of multiple different pathologies such as neurodegenerative diseases, neuromuscular disorders, neurovascular disorders/trauma and mobility for the elderly. This tool provides functional training so as to improve equilibrium, coordination, weakness, fatigue and spasticity. The exercises can be adapted to a patient’s disability levels so that the programme can be used with a wide range of ability levels.

How does it work?

Virtual Rehab utilises the unique characteristics of Microsoft Kinects motion technology to track and capture the movements of the patients so that patients become immersed in a 3D environment where they interact with the game. VirtualRehab Body programme allows patients to retain upper and lower limb motor functions. Patients are presented with an array of objects at differing heights and depths to be reached for with either hands or feet. Exercises can be performed whilst sitting or standing or a combination of both. Some of the games used include bullseyes & barriers, fit in the figure, reach for the balloon, row the boat and weightlifting. To see the full of list games and what they look like, click here www.virtualrehab.info/wp-content/uploads/2014/02/VirtualRehabBody_Games.pdf 

The structure of the exercise will be clearly defined and visual cues are provided for execution of the exercise eradicating the potential problem of forgetting a step in the exercise or the whole exercise completely. Furthermore, the Kinect motion technology will record the execution of the movement to provide feedback to the patient and the therapist on correct or incorrect movement performed. This can be used within clinics and hospitals as well as within the patients’ house so that rehabilitation can be continued at home. By providing highly motivating games patients are more likely to adhere to their rehabilitation programmes leading to improved outcomes . See what patients had to say about their experience of using VirtualRehab in section 7.1.

What is needed to play VirtualRehab?

• Microsoft Kinect Xbox One
• Microsoft adapter for Windows
• PC with windows (Windows 8 or above)
• TV with HDMI port
• Internet connection 

Pros for clinicians

• Simple to use Program Manager
• Individual monitoring for each patient
• Evaluation and graphical analysis of patient’s progress
• Allowing for progression or adaptation
• Remote control of treatment programs
• Patients adhere to treatment
• Provides objective rehabilitation measurements
• Alerts 

What do the therapists think?

Erika Otxoa, Physiotherapist - "Although at the beginning I was reluctant to use videogames, as of today, our experience shows that VirtualRehab is a viable, comfortable and simple to use tool which improves the patients’ quality of life"

Marcela Casilla, speaking of a patient – "Playing the ‘bail the water from the boat’ game allows her brain to connect with her hands to place them exactly where she wants to.The game gives the possibility to work Visuomotor coordination. Her movements are controlled and slow, and while playing she has to think to herself: ‘what do I have to, how far is the board in front ofme and how high do I have to reach to touch it?"

Laura Garcia, Physiotherapist coordinator –  "One of our patients is currently addicted (to VirtualRehab) in a good way, because VirtualRehab motivates her and encourages her to do things she wouldn’t do without the game on the screen in front of her, as she forgets about her (physical) limitations" 

Did you know?

As of 13th November 2015

VirtualRehab has clocked up:

• 13,697 rehabilitation sessions
• 1,378 hours of play 
  

Jintronix

Jintronix was set up in 2012 after the CEO Justin Tan’s father suffered a stroke whilst travelling on a flight from New York to Paris. After standing alongside his father through the long rehabilitation process and managing to rack up $250,000 costs, Justin became determined to find out whether technology could help this process. He eventually went on to create Jintronix with a few of his engineering friends. The purpose was to create an engaging, accessible and cost-effective stroke rehabilitation program which would motivate and improve patients’ overall experience of rehabilitation.

One way Jintronix achieved this was by developing an exercise platform that provides immediate feedback so that patients and clinicians can participate in the sessions at home or in hospital. The plan of Jintronix technology was to make repetitive rehabilitation programs more engaging and turn them into games that patients would enjoy playing. Once released from hospital, 65 percent of patients either don't do the prescribed exercises or are only partially adherent because they get fatigued easily and the exercises themselves are tedious. Therefore, solutions like the Jintronix have taken on the task of improving patient compliance and, ultimately, therapy outcomes.

How does it work?

The games were developed through researching which exercises and sports best fitted with conventional therapy. For instance, skiing enables the assessment of weight shifting. One of their most popular games “Fish Frenzy” moves the patient through various exercises while their fish is on the hunt for food. The player must control the fish’s movements up and down and draw a figure of 8 to make it eat. Another game called “whack-a-mole-style” was designed to strengthen leg muscles so that when a bunny pops onto the screen the patient must walk towards a specific part of the screen. Jintronix is capable of tracking a patients’ movements to see whether they are performing the activities correctly and relays this to the therapist who can then make adjustments. So far, there are seven games that have been created and work smoothly. See what patients had to say about their experience of using Jintronix in section 7.1.

Jintronix Studies

The team received FDA approval in May 2014 and the software is currently being beta tested at 60 clinics and hospitals around the world,, ). One such hospital is Launceston General Hospital where the University of Tasmania took on the task of setting up 5 consoles within the hospital where around 70 patients would be able to try Jintronix for themselves. The trial is still currently underway and reports and studies of its success in this hospital are expected to be released in the coming months. Dr Marie-Louise Bird, a lecturer from the university in the School of Health science also Jintronix trials’ chief investigator had this to say:

                               

At this same hospital a single case study was carried out by an 88 year old, 3 months post-stroke, patient trialling the Jintronix software and Microsoft Kinect motion sensor for full body rehabilitation using a pull to stand aid and standby table. Results suggest that active-assisted upper limb activities are possible, weight shift and balance activities are possible and the tracking system is capable of giving feedback on performance all whilst using a stand aid. Increased total activity time in rehabilitation, increased repetition of movements of both limbs are possible in stroke patients who cannot stand independently. Although this was a small scale study it has provided beneficial evidence that assistive devices are able to be used with this software. Therefore patients who are unable to stand independently would be able to utilise this software. This extremely important as following stroke many patients are left with debilitating effects and cannot stand or walk independently. It is valuable to know that patients with a range of physical limitations are capable of using Jintronix for rehabilitation .

There is still limited evidence of the effectiveness of Virtual Reality systems in the functional recovery after stroke. One reason this may be is because there is a lack of clinical guidelines for use with the software being used. This study looked into the possibility of developing guidelines for the Jintronix system in upper extremity rehabilitation after stroke. 14 stroke patients took part in three 20 minutes practice sessions. To begin with all patients arm impairment levels were measured using the Chedoke-McMasters (CM) scale. Each patient then ran through a range of difficultly levels on Jintronix, which has a total of 10, in order to find the level that suited their ability. All patients were able to progress their performance over three practice sessions. The data received from the study has given an insight into the relationship between arm impairment level of the patients and the difficulty level that patients were able to achieve on Jintronix. Thus giving clinicians an idea of what can be expected from patients with varying arm impairment levels so that precise goals can be made in relation to achieving a specific difficulty level. This study is just the beginning and ultimately the goal would be to create guidelines for prescription of UL training using Jintronix. This would mean that patients would not have to trial and error through the stages but would begin at their optimal level based on their CM score. Results from the questionnaires indicated that the majority of patients enjoyed the activities provided by Jintronix and found them easy to use .

Another study using the Jintronix system evaluated the kinematic validity of the Kinect camera for rehabilitation purposes and assessed the usability of Jintronix for patients and therapists. In order to assess validity of the Kinect is was compared against the gold standard; the Optotrak 3D motion capture system. A series of hand reaching movements, trunk leaning and elbow flexion and extension were performed by one healthy participant over each camera position and repeated three times. Both systems tracked the participant’s movements simultaneously and the captured frames were compared for each movement. Data received from the Kinect closely matched Optotrak after bias was removed. Thus, showing that the Kinect is a valid tool for monitoring hand position, trunk position and elbow angle.

Twelve therapists evaluated the Jintronix system based on usability and utility for rehabilitation. They were required to navigate the home page, use the calibration sequence and play 5 of the systems games. Participants then commented on the usability and rated different aspects of the system such as involvement of specific movements e.g shoulder abduction, wrist extension, range of motion etc. using a 5-point Likert scale. The therapists reported that all games were capable of training active range of motion, speed, precision, and shoulder flexion and extension. Furthermore, bilateral games required bilateral coordination and unilateral games trained elbow flexion and extension. Lastly, the trunk game was capable of training trunk movement and balance. All therapists were interested in using Jintronix in the clinical setting. Suggesting that Jintronix is a feasible system that can be used for rehabilitation purposes. There are currently 12 other studies being undertaken looking into different aspects of stroke rehabilitation such as balance and gait in which reports should be making an appearance in the coming year or so.

What is needed to play Jintronix?

• Microsoft Kinect for Xbox One
• Microsoft adapter for Windows
• PC with windows (Windows 8 or above)
• TV with HDMI port
• Internet connection
• Clinician to prescribe and monitor use 

Pros for clinicians

• Automated documentation
  

          Quick and efficient record keeping
          Less time filling out paperwork > more time for patients

• Strengthen compliance

          Remote access platform > detect issues patients may be facing whilst at home
          Flexible and adaptable > addresses patient goals
          Faster and more accurate movements

• More accessible

          Access to rehab remotely > decreasing patient need for clinic appointment > freeing up clinician time slots > decreasing wait list                   times

What do therapists think about it?

• Phillippe Archambault – The Jintronix solution is flexible and adaptable: it addresses patient goals to get better and make faster and more accurate movements
• Paula Riccio – In our industry, our customers need measurable outcomes, it’s where payment reform is going, it’s where regulatory reform is going, it’s a necessity that our industry is becoming standardised and Jintronix has been by far the best technology we found… it really is one of a kind in the market place 
• Listen to what they have to say:

Question time

1. What percentage of patients once released from hospital either don't do the prescribed exercises or are only partially    adherent?
2. List 4 Pros for clinicians using VirtualRehab or Jintronix
3. List what is required in order to play VirtualRehab and Jintronix
4. After watching Justin Tan at TEDxMontreal (see section 4.3.3), discuss the need for developing a new clinically                                              validated rehabilitation tool utilising technology
                               5. What anecdote is used from a patient using new technology in Justin Tan at TEDxMontreal youtube video (see section                                        4.3.3).

Key points

Key features of Microsoft Kinect hardware:

• RGB colour camera
• New active infrared (IR) capabilities
• Depth sensors
• Multiarray microphone

What the Microsoft Kinect sensor is capable of:

• Capturing 3D motion, facial recognition and voice recognition
• Can recognise up to 6 people
• Can track 2 people at a time
• Tracks 20 joint coordinates
• Captures 3D data independent of lighting conditions
• No controller needed

Advantages and disadvantages of Microsoft Kinect

Advantages

• Intensive therapy that has high potential in rehabilitation of stroke – rehab can be carried out at home.
• Inexpensive tool compared to long term rehabilitation sessions - retails at £ 129.99 for xbox and £199.99 for Microsoft.
• The accuracy of Kinect for clinical use is strong  . 
• Provides instant feedback to both patients and physiotherapists. 
• Kinect is an acceptable and affordable depth sensor for rehabilitation purposes- good accuracy and reliability . 
• Can increase motivation levels to complete home exercise programmes since they can be viewed as a fun activity .
• Does not require the use of any devices attached to the body or held onto by hand (i.e. motion sensors, hand-held remotes, standing on an object, etc.)
  

Disadvantages

• From a patient's perspective they may be reluctant to change and use this device.
• Games targeted at rehabilitation may be prone to “cheating” (e.g. excessive, unnatural and counter-productive trunk-based compensation)
• The current benefits of Kinect-based gaming have only tentatively been studied with mainly short term and small sample sized studies.
• Kinect systems are usually not suitable for severely disabled patients, as gross movements that remain very small in their entirety are challenging for the Kinect to precisely capture .
  
• Software is still in development
• Physiotherapists we will require training to learn how to use the Kinect (especially how to develop a patient’s home exercise programme through the Kinect).
• Social problem – patients may become house bound with their rehabilitation programme and become excluded from society.
  

Question time

 1.  Name 3 advantages and 3 disadvantages of Microsoft Kinect.

 2.  From a physiotherapist's perspective can you think of any other potential advantages / disadvantages that may                 be of concern?

                                 3.  As a physiotherapist would you be willing to increase your knowledge about Microsoft Kinect's                                                                           potential use in rehabilitation? Does its use appeal to you?

Considering microsoft kinect’s potential future in stroke rehabilitation: Emerging evidence

The Kinect has shown much potential for use in stroke rehabilitation but evolving evidence highlights its prospective use into specific areas of rehab for stroke. Below are examples of research into the effectivenss of Kinect  and how it can help with facial paralysis rehabiliation, upper extremity rehabilitation and balance rehabilitation. 

Facial paralysis rehabilitation

Of all the stroke cases that occur in the UK each year, around 16% of them will have long standing facial weakness. There is an increasing need, by the NHS, to provide cost effective community rehabilitation to these patients . Facial weakness rehabilitation has been investigated using the Microsoft Kinect by a team from Nottingham Trent University and the evidence suggests that it can be a useful device for this use . Patients can use Kinect to complete physiotherapy regimes by copying on-screen exercises, while doing so the system will compare the patient’s facial expression with that of a range of preconfigured facial poses . The patient will be guided through the exercises by an on-screen pre-recorded voice of a real therapist and feedback will be provided to the patient on how well they completed the exercises. An exercise programme can be individualised for each patient, whereby exercises might include alternating between ‘oo’ and ‘ee’ mouth shapes .

Upper extremity rehabilitation

Upper extremity rehabilitation using Kinect is perhaps the most studied intervention in stroke due to upper limb deficits occurring in over 66% of patients early after stroke . The effects can be highly debilitating which is most evident when there is a loss of manual dexterity. The use of therapy using Kinect-based systems maintained or improved the patient's motor performance . Most studies have only investigated mild to moderately impaired patients and have emphasised that it was particularly beneficial to those who have recovered significant amounts of motor functionality leading to question its effectiveness in the use with patients at different levels of recovery . However one study did include patients who were severely impaired and also mild to moderate cognitively impaired which still resulted in beneficial results from the majority of participants. By including a greater range of patients this increased the external validity and generalisability so assumptions can extend further beyond mild to moderately impaired populations . Kinect provides opportunities for gross arm movements exercises but fine motor control movements of the hand and fingers are more difficult to track . Another study looked hemiplegic stroke survivors who were beyond 6 months since onset in the use of Kinect along with conventional therapy. Results showed that all participants who took part improvement in all aspects of arm function. However the patients in the Kinect and conventional therapy performed better in terms of ROM, fugl-meyer assessment and the Box and Block test than those who only took part in conventional therapy .

Balance rehabilitation

Balance rehabilitation is possible in the stroke population using the Kinect. The patient stands in front of a screen while his/her movements are monitored using kinect. A pair of virtual shoes is displayed on the monitor following the patient's feet movements. The results of this study showed significant improvements in balance recovery as measured by the Berg Balance Scale (BBS) . Virtual Reality based telerehabilitation interventions are capable both in clinic and out of clinic (at a patient’s home) of achieving reacquisition of locomotor skills. In a group of chronic stroke patient improvements were made after 12 weeks of tele-rehabilitation using the Kinect in the BBS, the gait and balance components of the Tinetti’s scale and the Brunel Balance assessment . Thus indicating that balance rehabilitation using the Kinect in stroke patients is feasible and proving that at home rehabilitation is just as effective as in-clinic.

Other possibilities

As identified by Microsoft Research , long term plans for stroke recovery with Kinect include integrating social networking into the system so that stroke patients can connect with one another and participate jointly in the rehabilitation programme. This could offer patients emotional and psychological support and motivation. Within the community, patients would have the opportunity to communicate about their condition and receive encouragement as they advance towards recovery. Possible functionality could include guided exercises with both correctional and encouraging feedback, with variable difficulty levels, and performance reports and summaries for physiotherapy use. Future updates could make it possible for physiotherapists to monitor the patient’s rehabilitation from their office, and to communicate with the patient regarding their treatment and progress.

From the research gathered Microsoft Kinect could be used in a variety of settings that include hospital, home and community and would be a successful rehabilitation tool for stroke patients. More research needs to be conducted to enhance the knowledge about the devices capabilities and limitations.

Key points

    1.  Emerging evidence suggests that Microsoft kinect has high potential in rehabilitation of stroke suffers                                through its effectiveness in facial, balance,and upper limb rehabilitation.       

    2.  Microsoft Kinect can play a key part in rehabilitation in diverse setting to include hospitals, communities                            and in patient's home thus increasing patient's independence in performing their rehabilitation programme. 

                                    3.  Further research on Microsoft kinect and its use in stroke rehabilitation needs to carried out to develop our                                                        knowledge about its abilities and limits. 

Physiotherapist Role

What is Rehabilitation?

Physiotherapy rehabilitation aims are to improve or increase patient function and well as well-being. To get the patient back to their lifestyle, or as close to as possible.

Rehabilitation should focus on changes in the lifestyle and the functional disability. It should also focus on the patient's own goals for functional improvement.

Physiotherapists should be involved from the beginning, as evidence has shown that it speeds up recovery time. Early mobilisation is associated with better outcomes.

Primary goals of rehabilitation:
• Prevent complications
• Minimise impairments
• Maximise function

Patient Assessment

For every new patient an assessment will be carried out by a physiotherapist who has received training in the use of the Microsoft Kinect rehabilitation programme. The assessment will involve inputting data about the patient's weight, height, the range of motion in his/her limbs and body parts lengths. The range of motion and length of the body parts can be assessed by getting the patient to perform different exercises while the Kinect detects the measurements in 3 planes- frontal, sagittal and transverse. Obtaining accurate measurements will help provide information about the maximum flexion and extension ranges for specific joints and will make sure the patient carries out these exercises in a safe range to optimize efficiency of the rehabilitation programme . 

Rehabilitation Programme Design

An individualized rehabilitation programme will be designed by the physiotherapist by selecting exercises that are provided on the system. This programme will consist of a set of multiple exercises that will target specific joints or muscle groups. Due to the nature of stroke the left and right hands for example, can have different impairments which would lead to different exercises being provided to help achieve patient goals. The physiotherapist will choose the appropriate amount of sets and repetitions for each exercise to be performed depending on the impairments of the patient.

Performing Rehabilitation at Home

Once all the equipment has been set up in the patient's home the physiotherapist will go through the exercises that s/he would like the patient to perform.The user will be positioned at least 1.2m away from the camera. To begin the patient selects the “Start Rehab” button and the system prepares the individualized programme designed by the physiotherapist. As soon as the first exercise starts, there will be a message on the screen saying what to do. If it's an elbow extension exercise the message will say “Please straighten your (left/right) elbow as much as possible”. Instructions for each exercise will also be read out loud by the system (using Microsoft text to speech API). While performing the exercise the user will get visual feedback on the progress. If the exercises is not performed correctly, the repetition counter will stop until the patient's starts doing the exercise correctly and instructions will be provided on how to perform the exercise appropriately. The physiotherapist will track the patient's progress from the statistics that is stored on the system.Follow up will be done by ringing the patient on a weekly process to keep up to date with their progression with the rehabilitation programme . 

Advantages & Disadvantages of Microsoft Kinect for the Physiotherapist

Advantages in Physiotherapy
• Inexpensive tool
• Can download free beta version of Kinect for Windows software to create programs to be used on a PC

(http://research.microsoft.com/en-us/um/redmond/projects/kinectsdk/download.aspx)
• Provides instant feedback to both patients and therapists
• Does not require the use of any devices attached to the body or held onto by hand (i.e. motion sensors, hand-held remotes, standing on an object, etc.)
• Difficult to “cheat” when performing activities due to the camera’s ability to detect and sense whole body position
• Can increase motivation levels to complete home exercise programs since they can be viewed as a fun activity
• Can be used for gross motor upper extremity exercises for individuals in a wheelchair (Chang 2011)

Disadvantages in Physiotherapy
• Software is still in development
• Accuracy is questionable
• More research needs to be done to realize the full potential of the Kinect with respect to biomechanics
• Not all patients will own or be able to afford to purchase a Kinect
• Therapists will need training to learn how to use the Kinect (specifically how to develop a patient’s home exercise program through the Kinect)
Not all clinics will have a Kinect available for use (clinic’s will be required to purchase one)

ICF model and virtual rehab