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

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

Top Contributors - Sally Wood, Kate Reidy, Nicole Bell, Karen Feeney, Hannah Meredith, Leana Louw, Kim Jackson, Naomi O'Reilly, Joanne Knowles, 127.0.0.1, Admin, Chee Wee Tan, Evan Thomas and Michelle Lee   

 Introduction: Where it all began

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 clients.
• Critically evaluate the evidence behind Microsoft Kinect in the rehabilitation of stroke clients . 
• 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. 

Why sensors in healthcare are about to have their moment

Technology within rehabilitation has emerged dramatically over the past couple of years. Their capability and affordability are partly to blame for this . The future of health is about highly personalised care and putting the control of patient’s health back into their own hands . Sensors in healthcare are becoming more prevalent and their ability to detect even the smallest of movements more recently is making them very appealing. Sensors are capable of automating, large scale monitoring and measurement of health-related parameters. They are capable of diagnosing, treating and monitoring patients and providing clinicians with early warning signs for potential problems . They can also provide more objective feedback than a clinician stating subjectively how a patient’s body is positioned in space. Vinod Khosla stated that “In the next 10 years, data science and software will do more for medicine than all the biological sciences together” . Thus indicating that as Allied Health Professionals there is a need for us to develop our skills in technology in order to keep up with the rapidly progressing rehabilitation environment. One device in particular that has been developing over the past few years is Microsoft Kinect and it is rapidly developing into a very feasible option for rehabilitation in the stroke population.

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 One. 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, 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.

Recap of Stroke 

A stroke occurs when there is interruption of the blood supply to a particular area of the brain, ultimately leading to cell injury and cell death.

Strokes can be classified as either:

•Ischaemic

•Haemorrhagic

Ischaemic strokes are the most common, accounting for up to 80% of strokes, and occur when there is an occlusion of a blood vessel impairing the flow of blood to the brain.

What you will need to know as a physiotherapist

As future graduates and qualified physiotherapists working in clinical practice it is important to understand the potential emerging role of Microsoft Kinect in stroke rehabilitation.

You will need to know:

1.The key pieces of hardware needed to set up the Kinect
2.Which patients the Kinect would be appropriate for
3.How each programme/game works and the type of rehabilitation it provides
4.How to track patients progress and information

From this physiopedia page you should now be able to answer the questions above.

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. Other factors limiting access to rehabilitation services may include: a physical impairment preventing or restricting attendance at a local service, a lack of clinicians or specialists in a geographic area, or the insufficient provision of resources in a geographical region.

With the high prevalence rate of stroke this puts increased demand on physiotherapists to treat each client 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 clients they can be pushed further down the rehabilitation follow up list. Another challenge to effective rehabilitation is insufficient completion of rehabilitation exercises by clients which severely reduces the potential outcome of overall motor recovery. Exercises are often unpleasant and tedious leading to client'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 recognized that a strong rehabilitation service using 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 client 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 fulfill 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 clients home.
• Involve family members and carers more within the rehabilitative process.
• Help the NHS meet National Clinical Guidelines on physiotherapy interventions for stroke (45 minutes per day of treatment during the acute phase) 
• Improve client 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 client.
  
• Reduce transportation cost and time savings from the perspective of both the physiotherapist and client.
• Provide continuity of client care.
  

Question Time

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

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 clients 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:
https://www.stroke.org.uk/sites/default/files/stroke_statistics_2015.pdf 

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 utilise 3D depth cameras which enables people to interact with games using their own body in a natural way . A unique characteristic 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 .

Microsoft 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 an RGB camera, a depth sensor and a multiarray microphone providing full body 3D motion capture, facial recognition and voice recognition capabilities (see figure above) . 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 (see figure below). 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 clients’ 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 client outcomes. Motivation is improved as clients can work against themselves and see improvements no matter how small. Compliance is maintained due to the more exciting nature of the games making clients 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 clients 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 clients so that patients become immersed in a 3D environment where they interact with the game. VirtualRehab Body programme allows clients to retain upper and lower limb motor functions. 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 client and the therapist on correct or incorrect movement performed. This can be used within clinics and hospitals as well as within the clients’ 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 clients had to say about their experience of using VirtualRehab in section 6.3.1.

                                                

Game examples

• Bullseyes & barriers – static & dynamic balance, load transfer. The user must intercept the objects that appear on screen with their upper limbs and must avoid lower obstacles by raising their feet and step on indicated tiles
• Fit in the figure – flexibility, standing position, balance. The user must ensure the avatar shape matches their own
• Row the boat – bilateral upper limb training. The user must row and move their hands in a coordinated and parallel fashion
• Bail out the water – trunk control, body scheme, hand-eye coordination. The user must bail the water out of the boat using the pump which is activated by moving the hands in a parallel but inverted fashion.

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. Some examples are shown in the picture above.

What is needed to play VirtualRehab?

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

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 clients 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 client compliance and, ultimately, therapy outcomes.

How does it work?

The games were developed through researching which exercises and sports best fitted with conventional therapy. The rehab modules are adaptable to the level of a client's functional and cognitive abilities and are designed to train balance & mobility, muscle strengthening & endurance, flexibility & range of motion, fall prevention, postural control, motor control & relearning and bilateral coordination . Jintronix is capable of tracking a players’ 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 clients had to say about their experience of using Jintronix in section 6.3.2.

Jintronix can be used in 3 different ways:

• Integrated model – Clinicians use Jintronix with their clients during their one-on-one session
• Kiosk model – Clinician sets up Jintronix rehab program for client. Client performs their exercises with the help of an aide
• Telerehab model – Client uses Jintronix at home with remote supervision
  

Game examples

• Ski game – weight transfer & squatting. Player will move their avatar down a slope through various obstacles and performing different balancing movement 

• Fish frenzy – controlled movement. Player must will control the movement of a fish through the game, performing different exercises such as drawing figures of 8, moving up and down whilst on the hunt for food .

• Pop clap & garden crab – bilateral coordination games
• Whack-a-mole – lower limb strengthening & dynamic balance. Player must walk or hop towards a specific part of the screen when a bunny when it pops up onto the screen 

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:

                               

Trial using Jintronix software and Microsoft Kinect motion sensor for full body rehabilitation using a pull to stand aid and standyby table.

• 88 year old male, 3 months post-stroke
• 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.
• Beneficial evidence that assistive devices are able to be used with 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 ..

Development of guidelines for the Jintronix system in upper extremity rehabilitation after stroke.

• 14 stroke particpants took part in three 20 minutes practice sessions
  
• Participantsts arm impairment levels were measured using the Chedoke-McMasters (CM) scale
• Each participant 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.
• Data received has given an insight into the relationship between arm impairment level of the participants and the difficulty level that participants were able to achieve on Jintronix.
• Clinicians have an idea of what can be expected from clients with varying arm impairment levels so that precise goals can be made in relation to achieving a specific difficulty level.
• The ultimate goal would be to create guidelines for prescription of UL training using Jintronix.
• Clients would not have to trial and error through the stages but would begin at their optimal level based on their CM score.
• Majority of participants enjoyed the activities provided by Jintronix and found them easy to use .

Kinematic Validity of the Kinect camera for rehabilitation purposes

• Kinect 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.
• Kinect is a valid tool monitoring hand position, trunk position and elbow angle .

Usability of Jintronix for patients and therapists

• 12 therapists evaluated the Jintronix system based on usability and utility for rehabilitation.
  
• They navigated the home page, used the calibration sequence and played 5 of the systems games.
• Different aspects of the system such as involvement of specific movements e.g shoulder abduction, wrist extension, range of motion etc. were rated using a 5-point Likert scale.
• All games were reported as being capable of training active range of motion, speed, precision, and shoulder flexion and extension. 
• Bilateral games required bilateral coordination and unilateral games trained elbow flexion and extension.
• 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 
  

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 clients once released from hospital either don't do the prescribed exercises or are only partially      adherent?
2. List what is required in order to play VirtualRehab and Jintronix
3. After watching Justin Tan at TEDxMontreal (see section 4.3.3), discuss the need for developing a new clinically           validated rehabilitation tool utilising technology
                               4. What anecdote is used from a client 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 of Microsoft Kinect	Disadvantages of Microsoft Kinect
Intensive therapy that can be carried out at home	Many clients demonstrate significant levels of disability making it difficult to conduct rehabilitation using Microsoft Kinect.
Inexpensive tool compared to long term rehabilitation sessions- retails at £199.99 for Microsoft sensor	Recognition of clients- clients who present with hemiplegia, limited active movement in one arm or other similar postural deformities may find that the Kinect does not 'see' them. Similarly someone using a self propelled wheelchair will be recognized straight away, someone else using a powered wheelchair, with joystick control for example, may find themselves struggling to be noticed and registered by the sensors.
The accuracy of Kinect for clinical use is strong ,	Kinect systems are usually not suitable for severely disabled clients, as gross movements that remain very small in their entirety are challenging for the Kinect to precisely capture
Good test re-test reliability , and good repeatability	Games targeted at rehabilitation may be prone to “cheating” (e.g. excessive, unnatural and counter-productive trunk-based compensation) .
Can increase motivation levels to complete home rehabilitation programme since they can be viewed as a fun activity .	The current benefits of Kinect-based gaming have only tentatively been studied with mainly short term and small sample sized studies.
Does not require the use of attachments of sensor devices to the body or held onto by hand	Software is still in development
Simple to use	Social problem – clients 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?

The client and Microsoft Kinect

ICF model and Virtual Rehab

The International Classification of Functioning, Disability and Health (ICF) is a framework for describing and organising information on functioning and disability. It provides a standard language and a conceptual basis for the definition and measurement of health and disability

Aims of the ICF are:

· “To provide a scientific basis for understanding and studying health and health-related states, outcomes and determinants

· To provide a standard language and framework for the description of health and health-related states.

· It defines components of health and some health-related components of well-being (such as education and labour).”

The ICF model highlights the importance of all aspects of life.

The health condition which in this particular instance is stroke will have an impact on body functions and structures, activities and participation levels from the patient.

The ICF model is aware that all aspects including environmental factors and personal factors must be considered for the patient.

In figure ? The ICF model has been collaborated with Virtual Rehab in awareness that these factors are of great importance in the recovery and rehabilitation of all users.

Client's perspective on technology

The diagram below represents clients perspectives towards the use of technology. Clients views can be very powerful in the healthcare market and their voice should be heard (CSP 2012). Clients feedback in delivering services and bringing about change is highly important. The patient's experience framework should be considered here as it highlights respect for patient-centred values, preferences, and expressed needs (CSP 2012). More information on this can be found at the following website: https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/215159/dh_132788.pdf

From the client's viewpoint, decisions about whether or not to comply with rehabilitation programmes using technology are rational but often cannot be predicted by therapists (Campbell et al., 2001). Understanding the client will help with compliance to rehabilitation programmes that suits their needs and abilities.. Educating the client about the effectiveness of Microsoft Kinect as an alternative method to stroke rehabilitation will help relieve any concerns or worries that they may have.

Examples of client experiences

Using VirtualRehab

                                                                                                  

Using Jintronix

        

          

Key points

• Microsoft Kinect engages clients as well as help them improve at the same time
• Simple to use
• Comfort of your own home
• It is fun

Fun facts

• VirtualRehab’s Motto came from patients themselves. “Play. Enjoy. Improve! 
• Sales of Microsoft’s controller-free gaming system Kinect topped 10 million during the first three months after its          launch, setting a new Guinness World Record for the Fastest-Selling Consumer Electronics Device

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 the clients home thus increasing client 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

Client suitability for rehabilitation using Microsoft Kinect

Research suggests the following criteria should be taken into account prior to commencement of Virtual Rehabilitation.

• Cannot be too cognitively demanding for the patient (specificity to the individual is key).
• Motivational
• Motor recovery
• Emotional and psychological support
• 65% usually fail to continue rehab programmes due to cost or relying on transport.
• Early rehabilitation is key to recovery.
• Diagnosed with a non-cerebellar ischemic or hemorrhagic stroke >3 months prior to recruitment, be attending physiotherapy for balance or         mobility dysfunction.
• Clients who experienced a first stroke within 10–60 days prior to enrollment
• In Canada, rehabilitation is standard of care in the first three to six months after stroke
• Be able to stand unsupported for >30 seconds for balance rehabilitation.
• Mini Mental State Examination score ≥20.

Protocol for client assessment for rehabilitation programme

For every new client 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 clients 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 client 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 client 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 specific client goals. The physiotherapist will choose the appropriate amount of sets and repetitions for each exercise to be performed depending on the impairments of the client.

Performing Rehabilitation at Home

Once all the equipment has been set up in the client home the physiotherapist will go through the exercises that s/he would like the client to perform.The client will be positioned at least 1.2m away from the camera. To begin the client 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 client will get visual feedback on the progress. If the exercises is not performed correctly, the repetition counter will stop until the user starts doing the exercise correctly and instructions will be provided on how to perform the exercise appropriately. The physiotherapist will track the clients progress from the statistics that is stored on the system.Follow up will be done by ringing the client on a weekly process to keep up to date with their progression with the rehabilitation programme . 

Advantages & Disadvantages of Microsoft Kinect for physiotherapists

Advantages	Disadvantages
Provides instant feedback to the client. It is capable of identifying when the client is carrying out the exercises correctly, warning him/her otherwise and also saving the statistics in a report for a further professional analysis	The traditional physiotherapy approach involves significant physical contact with the client and the physiotherapist making it difficult for some treatments to be applied through Microsoft Kinect.
Individual monitoring for each client	Physiotherapists will require training to learn how to use the Kinect.
Evaluation and graphical analysis of client's progress- allowing for progression or adaptation	More research needs to be done to realize the full potential of the Kinect with respect to rehabilitation in stroke clients.
Provides objective rehabilitation measurements	Clinics will have to purchase the Kinect sensor if they do not have already have one
Quick and efficient record keeping
Decreasing client need for clinic appointments- decreasing waiting list times

Skills and Knowledge required

• Training will be necessary for the use of Microsoft Kinect software

         - Navigating the software screens
         - Learning how to use Program Manager
               - To create personalised exercise programmes to suit individual needs
               - Ability to analyse statistics received from the software
         - Setting up the system in clients home

• Be competent in using Microsoft Kinect as a rehabilitation tool for stroke patients.
• The physiotherapist should be willing to adapt and use Microsoft Kinect as an alternative method of rehabilitation
• Keep up to date with Continuous Professional Development using STARS, link provided.
• Stroke Training and Awareness Resources (STARS) http://www.strokecorecompetencies.org/node.asp?id=home

Effects of VirtualRehab softwares on clients