Maria Manuela Cruz-CunhaPolytechnic Insitute of Cávado and Ave, Portugal

Isabel Maria MirandaPolytechnic Insitute of Cávado and Ave, Portugal

Patrícia GonçalvesPolytechnic Institute of Cávado and Ave, Portugal

Handbook of Research on ICTs and Management Systems for Improving Efficiency in Healthcare and Social Care

Volume I

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Copyright © 2013, IGI Global. Copying or distributing in print or electronic forms without written permission of IGI Global is prohibited.

Chapter 06

DOI: 10.4018/978-1-4666-3990-4.ch006

António TeixeiraUniversity of Aveiro, Portugal

Carlos PereiraUniversity of Aveiro, Portugal

Miguel Oliveira e SilvaUniversity of Aveiro, Portugal

Joaquim AlvarelhãoUniversity of Aveiro, Portugal

Anabela SilvaUniversity of Aveiro, Portugal

Margarida CerqueiraUniversity of Aveiro, Portugal

Ana Isabel MartinsUniversity of Aveiro, Portugal

Osvaldo PachecoUniversity of Aveiro, Portugal

Nuno AlmeidaUniversity of Aveiro, Portugal

Catarina OliveiraUniversity of Aveiro, Portugal

Rui CostaUniversity of Aveiro, Portugal

António NevesUniversity of Aveiro, Portugal

Alexandra QueirósUniversity of Aveiro, Portugal

Nelson RochaUniversity of Aveiro, Portugal

New Telerehabilitation Services for the Elderly

ABSTRACT

The world’s population is getting older with the percentage of people over 60 increasing more rapidly than any other age group. Telerehabilitation may help minimise the pressure this puts on the traditional healthcare system, but recent studies showed ease of use, usability, and accessibility as unsolved prob-lems, especially for older people who may have little experience or confidence in using technology. Current migration towards multimodal interaction has benefits for seniors, allowing hearing and vision problems to be addressed by exploring redundancy and complementarity of modalities. This chapter presents and contextualizes work in progress in a new telerehabilitation service targeting the combined needs of the elderly to have professionally monitored exercises without leaving their homes with their

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INTRODUCTION

The world’s population is getting older with the percentage of people over 60 increasing more rap-idly than any other age group. The World Health Organization estimates an increase of 223 percent in the number of older people between 1970 and 2025 (WHO, 2002). By 2025, it is anticipated that there will be 1.2 billion humans over the age of 60 and this will continue to rise to about 2 billion in 2050. Ageing brings a decrease in function-ing associated with an increase in a variety of chronic diseases, which leads to greater use of healthcare services (WHO, 2002). This challenges the traditional healthcare system and the scarcity and cost of health resources are likely to limit the health system’s ability to appropriately respond to a population that not only wants to live longer, but to live with more autonomy and quality of life (Kairy, Lehoux, Vincent, & Visintin, 2009). One of the most common problems with elderly people is mobility. The need to attend a Health facility (e.g.: clinic) has repercussions in their daily life and that of their families.

The use of technologies in health has seen a remarkable development in recent years, bring-ing a new or unique terminology. If the word ‘telemedicine’ appears in the first articles in this issue, nowadays the concept of telehealth appears to be the one that best reflects the potential of this subject:

Telehealth is the use of electronic communications to support long-distance clinical health care, pa-tient and professional health-related education, public health and health administration (HRSA).

With suitable natural interfaces and the pos-sibilities offered by the next generation networks

(NGNs), the introduction of technological solu-tions can facilitate the daily life of the elderly, fighting isolation and exclusion, increasing their pro-activity, work capacity, and autonomy.

As part of telehealth, telerehabilitation is the use of electronic communication and informa-tion technologies to provide rehabilitation at a distance. It comprises two categories: assess-ment (the patient’s functional abilities in his or her environment), and therapy. Teleconferencing or teleconsultation are no longer the primary services that can be distance provided. In fact, in telerehabilitation we can now include digital monitoring, patient surveillance and real time applications (Shaw, 2009). As an alternative to face-to-face rehabilitation approaches, it offers the possibility to overcome geographical barriers or act as a mechanism to extend limited resources and enhance outcomes in populations with special needs (McCue, Fairman, & Pramuka, 2010).

Telerehabilitation has been explored in sev-eral fields: neuropsychology; speech, language and hearing; occupational therapy and physical therapy. For example, Tele-audiology (hearing assessments) is a growing application.

The concern of different professionals on this topic has resulted, for example, in the American Physical Therapy Association defining guidelines for the practice of telehealth. In this document, telehealth also encompasses a variety of health care and health promotion activities, including, but not limited to, education, advice, reminders, interventions, and monitoring of interventions (APTA, 2009).

The pressure to provide quality services for an increasing population is felt in the elderly care sector. Telerehabilitation may help minimise the pressure put on the healthcare system by the continuous ageing of the worldwide population.

need regarding interaction, directly related to age-related effects on, for example, vision, hearing, and cognitive capabilities. After a brief general overview of the service, additional information on its two supporting applications are presented, including information on user interfaces. First results from a preliminary evaluation are also included.

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The scarcity and cost of health resources limits the health system’s ability to properly respond to a population that not only wants to live longer, but live with more autonomy and quality of life.

Technologies usable by older adults, with their specificities, to provide new services in the areas of telerehabilitation and Ambient Assisted Living (AAL) are needed. In this paper, we present work in progress in such a new service, for telerehabilita-tion and/or telefitness. In very general terms, the service provides supervised remote exercise ses-sions at home or community centres, as a means to maintaining health and preventing illness.

This work is part of the Living Usability Lab for Next Generation Networks project (www.livinglab.pt), LUL for short, a Portuguese industry-academia collaborative R&D project, active in the field of live usability testing, focusing on the de-velopment of technologies and services to support healthy, productive and active citizens. The project adopts the principles of universal design and natu-ral user interfaces (speech, gesture), making use of the benefits of next generation networks and distributed computing (LUL Consortium, 2010).

BACKGROUND: PHYSICAL TELEREHABILITATION

Although aimed at the general field of telere-habilitation, as proof of concept we focused our attention on the subfield related to physical rehabilitation. Nevertheless, a major part of the information in this section is not specific to physi-cal telerehabilitation.

From the many ways to define (physical) rehabilitation we adopt the interesting definition used by the AAL Forum 2010 Track R5 (Reha-bilitation, Training, Assistive Technologies) (AAL Forum, 2010):

You must again be the director of your own life! You must train and rehearse to again be able to help yourself and gain independent living.

Telerehabilitation facilitates access to rehabili-tation services for clients who would otherwise be unable to access them for reasons such as distance from a healthcare facility, lack of trained clinicians in their geographical area or mobility impairments. It also allows the provision of re-habilitation services to remote and underserved populations, resulting in improved quality of life and prevention of secondary complications, decreasing the need and frequency of travelling to healthcare centres and allowing health profes-sionals to interact with clients and their families more often and follow them up after discharge (Theodoros & Russell, 2008).

According to (Burdea, 2009, p. 50) “the one-to-one paradigm of therapy will also change, with one therapist performing “multiplexed” telerehabilita-tion. This is expected to reduce treatment costs while also increasing access to therapeutic care worldwide.” New technologies can help provide therapy anywhere, anytime, addressing current limitations due to location, lack of transport or limited therapist availability (Burdea, 2009). This author also predicts that cloud computing will be extended to cloud rehabilitation, where the library of disability-specific software simulations or games will reside on a third-party “cloud”; the clinicians will log on to set up exercise programs, follow up progress, ensure compliance and moni-tor safety.

Telerehabilitation has some advantages (Bur-dea, 2003). Particularly relevant for older adults are: availability of therapists, rehabilitation at home, reduced therapist cost and reduced isolation. Telerehabilitation shows promise in helping to minimise the pressure put on the healthcare system by the continuous ageing of the worldwide popu-lation. It constitutes a means of providing quality health care services that reach a high number of individuals at a low cost and that are adjustable to the individual needs of each client (Kairy, et al., 2009). Moreover, it provides an invaluable tool to implement activity programmes aiming to keep the elderly as active as possible and therefore

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prevent their loss of autonomy and independence, in line with World Health Organization policies and its definition of active aging (WHO, 2002).

The disadvantages, also according to (Burdea, 2003), are: equipment costs, demand on network bandwidth, technical expertise, safety at home, sterilization for redeployment, potential for ef-ficacy reduction, psychological factors.

The next generation networks will certainly decrease the problems of network bandwidth; technical expertise can be addressed by easy-to-use interaction; costs will drop as the number of users increases.

Telerehabilitation breaks with the traditional way of delivering health care, where the patient and the health professional are face-to-face. Thus, two main concerns arise regarding the acceptability of this new way of providing care for both clients and service providers, and the effectiveness of the care provided.

Regarding the acceptance of telerehabilitation services, studies have shown that clients have mixed feelings towards this new service. They fear the loss of treatment motivation and human support received in face-to-face treatments, but they value telerehabilitation as a complementary or follow-up treatment, reduction of transport difficulties, flexible exercise hours and the pos-sibility to better integrate learned skills into daily life (Cranen et al., 2011; Steel, Cox, & Garry, 2011). It is reasonable to expect that some older adults may exercise less without direct therapist intervention, since they feel they get less attention than they deserve. It is also reasonable to expect that others will be perfectly willing to accept less human contact (Burdea, 2003). It is possible that a period of transition between the traditional model of healthcare service and telerehabilitation services or the combined use of both ways of care provision will attenuate patients’ fears.

Despite the mixed feelings towards telerehabili-tation, studies comparing the level of satisfaction with healthcare services of a group of patients receiving telerehabilitation and a group receiving

traditional care found no significant differences between them (Hopp et al., 2006; Tousignant et al., 2011; Whitten & Mickus, 2007). For telerehabilita-tion to be used, it is also necessary that therapists believe it meets the criteria for a safe and effective rehabilitation service. Evidence seems to suggest that this is the case and that therapists believe it is also easy to use and could be easily integrated in their current clinical practice (Huijgen et al., 2008; Russell, Buttrum, Wootton, & Jull, 2004).

Concerning the effectiveness of telerehabili-tation, two recent systematic reviews of studies comparing telerehabilitation and conventional treatment have shown that interventions for a vari-ety of conditions and clients, such as neurological, cardiac or psychological conditions, delivered by telerehabilitation produce similar outcomes to treatment delivered in-person (Kairy, et al., 2009; Steel, et al., 2011). The outcomes assessed by the included studies were broad and included activities of daily living, return to work, lower limb range of motion, gait, pain, exercise capacity, cogni-tive tasks, speech quality, skin integrity, quality of life, fatigue, anxiety and depression (Kairy, et al., 2009). In addition, clinical process outcomes, such as attendance and compliance with treatment, seem to be higher with telerehabilitation than with conventional treatment. There is also some preliminary evidence of potential cost savings for the healthcare system (Kairy, et al., 2009).

Recent Related Work

A systematic review of related work being outside the scope of this chapter, to better contextualize the work presented, relevant information from recent papers in the area are presented in Tables 1 and 2. A comprehensive search in Advanced Scholar Search from 2010 was conducted using the keywords “telerehabilitation” and “tele-rehabilitation”; the first 20% (approx.) returned by the system were analyzed. In the analysis process, a few were discarded as they were considered as being too far removed from the work and objec-

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tives established for the new service presented in this chapter.

There has been investment in the development of systems and technologies related to telereha-bilitation particularly in Europe and USA.

The main users of such systems are in general people with physical disabilities, namely: tetraple-gia (Jan Kowalczewski, et al., 2011); joint prob-lems (Eriksson, et al., 2011); breathing problems (Dinesen, et al., 2010); limb disorders (Cabana, et al., 2010; Peng, Yang, Song, & Qin, 2010b; Russell, et al., 2010); elderly (Peel, et al., 2011); physical impairments (Anderson, et al., 2010; Tang, et al., 2010; Wai, et al., 2010) and cerebral palsy (Golomb, et al., 2010; Huber, et al., 2010).

Some systems (fewer) are intended for other types of impairments, such as cognitive impair-ments: Stroke (Gervasi, Magni, & Zampolini, 2010a; Huber, et al., 2010) and traumatic brain injury (Gervasi, et al., 2010a).

It was found that the technologies used are: computer games (Kowalczewski, et al., 2011); videogames (Golomb, et al., 2010); joystick (Kowalczewski, et al., 2011); Wii (Anderson, et al., 2010; Dinesen, et al., 2010); telekat (Dinesen, et al., 2010); X3D and Ajax 3D (Gervasi, et al.,

2010a), java3D games on modified Playstation 3 (Gervasi, et al., 2010a), and sensors (Wai, et al., 2010). And the systems used are: Robot systems (Peng, et al., 2010b); eHab (Peel, et al., 2011); distributed visual rehabilitation systems (Tang, et al., 2010) and physical therapy service (Russell, et al., 2010).

In general, all articles reviewed showed posi-tive results, indicating that telerehabilitation has potential for the rehabilitation of physical and cognitive impairments.

OBJECTIVE: A NEW GENERATION OF REMOTE PHYSICAL REHABILITATION SERVICES FOR THE ELDERLY

The Need for a New Generation of Services

From the recent literature in the area of physi-cal telerehabilitation, there is a noticeably small number of studies addressing active older adults, particularly when staying in their own homes. A very interesting exception is the study made

Table 1. Sample of recent related work (2011)

Study Users Technologies Used Results / Comments

(Jan Kowalczewski, Chong, & Galea, 2011)

Spinal cord injury survivors with tetraplegia

Computer games played with a trackball, and therapeutic electrical stimulation (Rehabilitation Joystick for Computerized Exercise (ReJoyce))

Scores improved more after ReJoyce Exercises Therapy than conventional. FES-ET on a workstation, supervised over the Internet, is feasible and may be effective for patients who can meet the residual motor function requirements of this study.

(Peel, Russell, & Gray, 2011)

Elderly eHAB™ in-home video-conferencing system

To implement telerehabilitation more widely in older people there are barriers to be overcome relating to patient limitations (hearing and/or vision impairment, client/carer anxiety, lack of space in the home, and cognitive impairment), staff issues and the logistics of the system.

(Eriksson, Lindström, & Ekenberg, 2011)

Patients with joint replacement

Videoconferencing with broadband connection (256–768 kbit/s)

The patients described experiences of safety and strengthening during their daily exercise routine at home. The frequent interplay with the patient during telerehabilitation made it possible for the physiotherapist to make an individual judgment about each patient.

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by (Peel, et al., 2011). These authors conclude that “Telerehabilitation has the potential to be a practical alternative for delivering rehabilitation services in targeted patients, especially in remote communities with limited access to services” (p.

366), but consider that several issues need further work to ensure effectiveness for elderly people. One of these issues is “ease of start up and use (...) especially for older people who may have little experience or confidence in using technology

Table 2. Sample of recent related work (2010)

Study Users Technologies Used Results / Comments

(Dinesen et al., 2010)

Chronic obstructive pulmonary disease patients

Telehomecare technologies – telekat; stepcounter, wii consult

Patients got more aware of their own symptoms; interaction between patients and professional got more based on “everyday-life problems”.

(Gervasi, Magni, & Zampolini, 2010b)

Traumatic brain injury and stroke patients

X3D and Ajax3D technologies; Nu!RehaVR system

There were more stimulating to the patients performing actions in relatively dangerous scenarios.

(Peng, Yang, Song, & Qin, 2010a)

Patients with upper limbs movement disorders

Combined robot system for assisted tele-rehabilitation based on remote operation technology and medical devices.

The adoption of computer network technology allows the patients to accomplish rehabilitation according to the settings of the physicians via Internet; the applications of virtual reality technology greatly raise the enthusiasm in patients and improve the rehabilitation effect remarkably

(Cabana et al., 2010)

Patients who had lower limb orthopedic surgery recently

Videoconference link and remote clinical station over residential DSL lines at 512 kbps.

Clinical variables typically measured in face-to-face evaluations can be measured successfully under telerehabilitation conditions with moderate reliability.

(Tang, Guo, & Prabhakaran, 2010)

People with disability Distributed virtual rehabilitation system (portable immersive facilities, along with a haptics-based exercise platform).

Through this system, therapist can monitor patients’ motions instantly and give evaluation and feedback immediately. Thus tele-guiding and tele-evaluation become possible using thissystem.

(T. Russell, Truter, Blumke, & Richardson, 2010)

Patients with nonarticular lower limb musculoskeletal conditions

Physical therapy service . Using telerehabilitation for musculoskeletal physical therapy assessment of nonarticular lower limb conditions was found to be valid and reliable.

(Anderson, Annett, & Bischof, 2010)

Patients with various impairments (balance, stability, movement precision and postural control)

Virtual Wiihab Wiihabilitation offer promising alternatives to traditional rehabilitation techniques. The new system, Virtual Wiihab combines the flexibility of VR rehabilitation techniques with the availability and enjoyment of Wiihabilitation.

(Golomb et al., 2010)

Adolescents with hemiplegic cerebral palsy

Remotely monitored virtual reality videogame telerehabilitation

Remotely monitored virtual reality videogame telerehabilitation appears to produce improved hand function and forearm bone health in adolescents with chronic disability who practice regularly.

(Huber et al., 2010)

Adolescents With Cerebral Palsy due to perinatal stroke or intraventricular hemorrhage

Fifths Dimension Technologies Ultra sensing glove and played custom-developed Java 3D games on a modified PlayStation 3

Significant improvements in finger range of motion were associated with self- and family-reported improvements in activities of daily living. In online subjective evaluations, participants indicated that they liked the system ease of use, clarity of instructions, and appropriate length of exercising.

(Wai et al., 2010) Patients who underwent surgery or suffer temporary physical impairments

Multimodal sensor network With the use of advanced sensing, intelligence and communication technologies, management of PT exercises can be done at home without disturbing or limiting the rehabilitation process.IG

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such as computers” (Peel, et al., 2011, p. 366). The same authors expect that developments in technology are likely to improve the user interface, contributing to increased accessibility.

According to (O’Connell, 2009) the current migration from WIMP interfaces towards mul-timodal interaction has benefits for seniors. For example, speech can accompany a text signal in a warning message box.

Efficient multimodal interfaces should be able to take into account the user’s capabilities, needs and preferences. This is particularly relevant for a group such as older adults. Age-related eye problems are a major cause of vision loss or distortion in people over 40, the risk of serious vision problems increasing with age. The effects of ageing on the structure and functioning of the speech organs are well known. Age-related changes (reduction in respiratory efficiency; calcification and ossification of laryngeal carti-lages; atrophy of laryngeal muscles; changes in articulators; loss of teeth; reduced musculature of tongue) affect the precision of articulatory ges-tures, fluency, voice quality and communicative effectiveness. Another consequence of ageing is hearing loss (Schneider & Pichora-Fuller, 2000). Hearing sensitivity decreases progressively with age (Moscicki, Elkins, Baum, & Mcnamara, 1985; Pearson et al., 1995). Presbycusis (Huang & Tang, 2010; NIDCD), age-related hearing loss also becomes more common in people as they get older. These problems in hearing contribute sub-stantially to difficulties in speech comprehension, especially in adverse listening conditions, includ-ing noise and reverberation (Helfer & Wilber, 1990). Another common problem is older adults’ difficulty in understanding rapid speech due to age-related changes in peripheral and/or central hearing abilities (McCoy, Tun, Cox, & Wingfield, 2005; Schneider, Daneman, & Murphy, 2005). This effect is usually attributed to a generalized slowing in the cognitive and linguistic functions of brain with age (Wingfield, 1996). However, auditory decline could also be responsible for

the elderly listener’s difficulty in accurately rec-ognizing rapid speech (Schneider, et al., 2005). Increasing the speech rate tends to degrade and/or distort the spoken message and it is possible that the auditory system of older adults is less effective in handling these distortions.

In scenarios such as interaction with older adults, where the hearing and/or vision ability of users can be reduced, it is useful to provide output for other senses, thus increasing the likelihood that system messages are received and perceived by the user.

Environment and context of use can also have a high impact in application or service use. Ex-amples of relevant environmental alterations are the increase of ambient noise level and changes in illumination. It is essential to determine these variations in context and adapt the system interac-tion inputs and outputs accordingly.

Also, the evolution of the link between in-formation and communication technology and the field of rehabilitation needs to change from concentrating on developing individual products to delivery of more complex services.

Combining the needs of the elderly to have professionally monitored exercises without leav-ing their homes with the availability and cost of qualified health professionals and the above-mentioned trends and needs regarding interaction, a Telerehabilitation Service was considered as one of the priority new services to develop and test in the scenario of our Living Usability Lab. The service is inspired by, but not identical to, the rehabilitation service proposed by project Persona (PERSONA, 2008).

The new service should address the goals of several very important groups: the elderly, health professionals in related areas, institutions active in the area and the National Health System. The first group’s goals include: to be able to perform exercises for rehabilitation or fitness purposes, with monitoring by health professionals, without the need to leave their homes; have faster and more convenient access to such services; use this new

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health service in an attractive, simple and secure way. Health professionals want to be able to ex-tend their practice geographically (even crossing borders to provide transnational services); provide services to people that cannot leave their homes easily or live in more isolated regions; have the possibility to combine competences with others, to create multidisciplinary services. Health institu-tions and the National Health System want to be able to send people home from hospitals earlier by assuring a rehabilitation plan at home and to improve the health of an increasing part of the population, reducing problems and increasing productivity.

The LUL Telerehabilitation Service with Multimodal Interaction

In general terms, the service should allow super-vised remote exercise sessions at home or at com-munity centres, as a means to maintain health and prevent illness. It should be possible for the user to wear biosensors (ex: surface electromyography). A health professional (physiotherapists, gerontolo-gists, etc) configures the sessions and supervises everything, including biosensor signals captured remotely and the video feeds from cameras.

To characterize both groups of end users (the elderly and health professionals) and support the development process – starting in Requirements analysis - three Personas (an archetypical represen-tation of real or potential users) were developed:

1. Mrs Zulmira, representing our active elderly users, aged 70, a retired secretary from a small company in a semi-rural area. Her relatives, who live nearby, work full-time. She has osteoarthritis, hypertension, pres-byopia and some hearing problems. Her family physician strongly recommended an exercise program, but her restrictions in using public transport prevent her from attending the exercise class;

2. Flávia Conceição, 32 years old, is a Gerontologist specialized in adapted physi-cal activity. She has experience in working in private charities with frail old people, developing activities and exercise programs. She is very fond of social networks and their supporting technologies, such as Microsoft Messenger;

3. Dr. Filipa, a 55-year-old Hospital Physician specialized in rehabilitation. She is married and has responsibility for taking care of her parents (living nearby). She uses computer applications professionally (e.g.: email and word processors), but with some reluctance. She does not have a laptop or smartphone.

The main user interface for the elderly should be a large size computer monitor, acting as a large size TV, combined with speakers and video cameras.

The service infrastructure should make it pos-sible to carry out sessions concurrently at several sites, connected to Next Generation Networks (in general, supported on fiber).

Usability and the use of Multimodality being central to the LUL project and, we expect, for the new service presented here (the service to be devel-oped must aim at a high usability and acceptance score), we adopt from the start the AMITUDE model proposed in (Bernsen & Dybkjaer, 2009). It is a generic model of the aspects involved when someone uses a multimodal system, providing designers with a conceptual development-for-usability framework that allows description of all aspects of system use which must be taken into account when developing multimodal usability. We presented in (Teixeira, Pereira, Oliveira e Silva, Alvarelhão, et al., 2011) an analysis of our system according to AMITUDE properties. Par-ticularly relevant and deserving mention here are the Devices and Modalities identified as necessary for interaction with the service by the two types of users. The choices are presented in Table 3.

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Main Requirements for the Service

Because usability is crucial, the method adopted for service creation involves user inputs from the requirements stage. Usability will not only be evaluated at the end of the development process; a first prototype was developed to integrate evalu-ation even in the requirements stage. To enable the creation of this prototype as soon as possible, a first draft version of requirements was obtained based on the characteristics of the Personas, their goals and descriptions of usage scenarios, a method inspired by the PSG (Persona + Scenario + Goal) method of (Aoyama, 2007). The results are sum-marized below. More details were presented in

(Teixeira, Pereira, Oliveira e Silva, Alvarelhão, et al., 2011). The service and, as far as possible, the prototype must comply with the following:

Functional requirements:1. Session management.2. Definition of the exercise plan, choos-

ing the exercises to include and the steps of each.

3. Facilities to the Health professional sending information on the exercise plan to the elderly and controlling its execution.

4. Allow feedback from the elderly.5. Allow the elderly to set preferences,

such as font sizes.Non-functional requirements (only the most

relevant):1. System must be reliable - Given the

type of operations being performed, it is crucial that the system remains operational and stable; it is essential for the system to possess fault-tolerant capabilities in order to continue operat-ing even in the event of a failure.

2. Distributed and heterogeneous com-puting environment – to cover the geographically distributed nature of the service and to avoid the need for specific computing environments.

3. The system must be scalable and ex-tensible - It must be ready to grow in the future and be capable of integrating new functionalities.

4. The system must log all system and users’ activities - This is crucial for the Living Lab paradigm.

5. The system must be highly usable. This is, without doubt, the most important of the non-functional requirements for this new service. The user must be com-fortable interacting with the system; it should feel simple and natural to him/her. This high-level requirement creates

Table 3. Devices and modalities for interaction of the two types of users with the service. For modalities, we use the terminology recommended in Bernsen and Dybkjaer (2009).

Input Output

Health Professional

Devices Microphone and speech recognition Keyboard Mouse Touch-enabled graphics monitor.

Graphic display Loudspeakers

Modalities 2D analogue haptics pointing (mouse) 2D static Portuguese typed text (text typed using a real or virtual keyboard) Portuguese spoken conversation

Portuguese spoken conversation Video imaging 2D static Portuguese typed text

Elderly User (at Home)

Devices Microphone and speech recognition, Video camera Biosensors Sensors to support context-awareness

large graphics TV with DVI or HDMI input connectors loudspeaker and text-to-speech

Modalities 2D static Portuguese typed text Portuguese spoken conversation 3D Video Streaming (movie)

2D static Portuguese typed text, Portuguese spoken conversation, 3D dynamic graphics describing exercises .

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a set of Human Computer Interaction (HCI) requirements, the most relevant being:a. Redundancy of modalities must

be used in order to increase the chances of message delivery and to make the system usable by speech and hearing-impaired persons.

b. Output modalities must be ca-pable of adapting to changing environmental conditions (light, noise, distance, etc.) and to users’ needs, limitations and personal choices.

c. Based on their preferences, allow users to be informed through their preferred modality(ies).

d. Text and graphic information readability at the distance needed for exercise execution must be optimized.

e. Interaction with users must use simple words and sentences.

f. Speech rate used by speech synthesis must be adapted to the listener and listening conditions.

g. Multi-touch input should be avail-able on the health professional side in order to allow him to eas-ily access information or quickly select a course of action.

SERVICE PROTOTYPE DESCRIPTION

In order to include, as early as possible, its final users in the development loop, we have chosen to create a minimal working prototype, able to perform a remote session with an elderly person at home (or in an institution) and a health care professional. The information extracted from the use and evaluation of this first prototype is being used to refine and modify future versions.

A broad overview of the service is shown in Figure 1.

The service provides the health professional with information from the house (e.g.: video) and

Figure 1. Global view of the service

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control over the rehabilitation session. The el-derly person at home receives indications for performing the exercises. This transmission is enhanced by the use of multimodality and adap-tation of the interface to his/her capabilities and environmental conditions.

Service implementation adopts a Service Ori-ented Architecture (SOA) approach. This choice appeared as natural given the requirements for a decentralized, modular, and highly heterogeneous computing environment. The separation into abstract services is also advantageous in terms of development time, reusability and scalability properties.

Creation of a prototype for the service depends on: (1) the development of two applications with suitable Human Computer Interaction, one for the elderly at home, and the other for the health professional planning, monitoring and evaluating the session; (2) the necessary network connec-tions and services (e.g.: to transmit video); (3) the existence of the health professionals and elderly to provide and use the service.

Both end user applications (shown in use in Figure 2) were built with a multimodal Human Computer Interaction tailored to each specific application goal, and to the expected different capabilities of its users.

Adaptive Multimodal Output

The main novelty of our prototype’s architecture is the focus on communication between the system and the user: multimodal output.

In general, systems in this area of application incorporate various modalities to communicate with the user (such as voice, text or images) but they are completely devoid of any autonomy, i.e. simply output the messages they receive using default definitions. In the proposed model, these modalities are intended to have some independence and self-adaptability to the user and context of use (e.g.: environment).

The current agents capable of transmitting information from the system to the user - synthesiz-ers in multimodal interaction literature - include two important mechanisms: The first is capable of deciding if in the current environmental conditions and taking into consideration user capabilities, he/she is in a position to be active and fulfil the request. For example, if the user is hearing-impaired or the noise level is too high, the synthesizer deactivates itself. The second changes some of the properties of the message to be transmitted, also based on contextual and user information.

Presently, and as proof of concept, using simple heuristics the text synthesizer varies the font size

Figure 2. Photo shoots of both applications in use during the first evaluation test. On the left, the ap-plication for the health professional (showing use of touch to control the remote camera); on the right, one of the evaluation participants doing an exercise, with (zoomed) superimposed information on the interface seen at his side.IG

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as a function of the user’s visual capacity, environ-mental lighting conditions and distance between the user and the screen. The speech synthesizer is capable of varying both volume and speech rate. This increases the chances of the message being received and understood. The context and user models, implemented as services, are crucial to make these two mechanisms possible.

To illustrate the use of our architecture with multimodal output adaptation capabilities, a relevant scenario is presented in Figure 3, where the system adapts itself using the perceived en-vironment in four steps. During the execution of an exercise the user steps away from the screen for some reason (step 1 in the Figure 4). With this event, environmental sensors detect a change and update the user’s distance to the screen. Im-mediately, the sensor informs the context model of this fact, associating the captured value (step 2 in Figure 4).

As the context model allows clients to subscribe to given events, in the current case, the user ap-plication has initially subscribed for distance

modifications. As such, the sudden change in the environment is reported by the context model to the application (step 3 in Figure 4).

The application uses this value to increase or decrease the font size in order to provide higher rates of usability. When notified of change, it im-mediately updates the font size and consequently, the user interface (step 4 in Figure 4).

Health Professional Application

The main goal of this application is to provide maximum and easy control over the rehabilitation sessions. In this sense, it allows health profession-als to: remotely monitor the elderly using video and biosensors; plan, apply and control an exer-cise program; provide the elderly with feedback regarding their performance.

Health Professional Interface

The following image illustrates the graphic inter-face of the health professional.

Figure 3. Adaptive multimodal architecture

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The health professional interface has five dif-ferent visual components:

1. Exercise selection2. Bio Sensor information3. Chat4. Video5. Session status information.

In the first component, Exercise selection (marked number 1 in Figure 5), the health profes-sional can monitor the exercise session by selecting or deselecting the exercises that the elderly user must perform.

In the second component, relative to sensor information (marked number 2 in the figure), the health professional can observe and analyze the bio sensors’ information of the elderly person. With this information, the health professional can guide and adapt the exercises to the patient’s condition at that particular moment.

In the third component, the Chat (marked 3), the health professional can directly communicate with the patient via text messages.

The Video component, 4 in the figure, pres-ents the image of the client. This component is an important tool for monitoring a session, as it enables the health professional to visualize the user’s performance and check completion of the exercises, allowing him to correct errors and give different indications to the elderly person.

Finally, the last component, session status information, allows the professional to track an ongoing session, regarding details about the con-nection and current exercise state.

Elderly Application

Special attention was given to the interaction on the elderly side of the application. The elderly pose more difficult interaction challenges because of their average expected physical limitations,

Figure 4. Sample AdaptO scenario, illustrating the main steps in the adaptation of font size in response to a change in user distance to the display

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varying individual capabilities (hearing and vi-sion acuity, for example), context conditions (such as light and noise levels, and distance from the devices), and the freedom of movements intrinsic in physiotherapy. Our efforts in this application have resulted in an architecture named AdaptO (Teixeira, Pereira, Oliveira e Silva, Alvarelhão, et al., 2011; Teixeira, Pereira, Oliveira e Silva, Pacheco, et al., 2011).

Since it is intended to provide useful health services to the elderly, two input and output mo-dalities were given special emphasis: speech and text. The use of speech derives from its potential to be usable by visually disabled people and to enable hands-free interaction at some distance from the devices.

This ability to receive information and give commands to a computer a couple of meters from the TV/computer display is essential when the aim is to do all body movement exercises. On the other hand, text based interfaces allow adaptability to hearing-impaired users.

The main user interface is a large size computer monitor (or a large TV). A set of biosensors gather signals from the elderly and send them to the health

professional’s remote application. In addition, it includes input and output devices such as micro-phones, speakers and video cameras, required for the interaction between users and the platform, and sensors to detect environmental factors.

User Interface for the Elderly

Figure 6 illustrates the graphic interface of the application for use by the elderly at home.

The user interface of the application has seven different visual components, divided into three blocks (corresponding to the 3 lines used to organize components):

1. Monitoring area, top line, including com-ponents 1 to 3.

2. Reception information area, in the middle and aggregating components 4 and 5.

3. User input area, at the bottom, for the last two components.

The Monitoring Area: Presents the summary of the session state at a global level. This allows the user to be aware of what is happening at any

Figure 5. Health professional application interface

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time, contributing to his orientation. The first component (Session State), corresponding to 1 in the figure, includes the description of the session state (active/inactive), and multimedia state. In order to promote user awareness, the application must always show time and date. The first time the application runs, a configuration button ap-pears, which allows the user to configure audio volume and text size. The second component (Log) describes the latest actions taken by the health professional and the elderly person in addition to the latest executed commands. The third component (Exercise State) shows the list of exercises scheduled for that session and highlights the current one. The component also includes a progress bar indicating the current remaining time until the end of the exercise.

The Reception Information Area: Presents all received information from the health profes-sional or from the service to the elderly person. The fourth component (Activities presentation) shows an animated presentation illustrating the current exercise, by use of SMIL (Synchronized Multimedia Integration Language), a language used to describe the animation which supports

text, images, audio and video. Each shown pre-sentation contains an explanation of the exercise to be performed, using a pre-established database of exercises.

The fifth component (Self Video) presents the image of the user, promoting the user’s aware-ness of his body, by allowing him to realize if an exercise is being performed correctly. With this, the user can possibly correct his posture or detect technical errors. This component may also visualize a Kinect 3D representation of the user’s own joints and central axis, hence enhancing his postural self-awareness.

The User Inputs Area: Presents all the infor-mation sent to the health professional or to the system. In the sixth component (Chat), the user can read messages typed by the health professional and if necessary write a message in return. The seventh component (Command list) shows pos-sible commands for the user to interact with the system and according to the state of the session, it can suggest different commands.

Figure 6. Elderly application interface

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FIRST EVALUATION

The new service is being tested by the end users (elderly and health professionals) in order to assess their acceptance and obtain feedback for further refinement and improvement of the service defini-tion and functional specifications. The primary purpose of collecting data is to provide information on usability and user satisfaction. Additionally, they allow refinement of the service requirements.

Method Adopted

The prototype evaluation phase is part of the ge-neric evaluation methodology, based on a living lab perspective, being developed in the project LUL.

The methodological plan was based on a series of procedures that fit the living lab approach. A central methodological aspect was inclusion of end users in the evaluation from the beginning. At this stage, a small sample, without much control but with a reasonable knowledge of technology and a good state of health, was considered enough, considering that we intended to test the potential of the service, layout, usability and satisfaction. Forthcoming stages of evaluation will include larger and more representative samples. Another central aspect of the methodology is the use of a combination of methods such as registration of critical incidents and filling in questionnaires. Questionnaires were created based on the Interna-tional Classification of Functioning Disability and Health (ICF) qualifiers of environmental factors; participants rate each item, expressing if it was a barrier or a facilitator.

Data collection was divided into two evalua-tion moments:

1. Evaluation during the session2. Post-Evaluation

Evaluation Procedure

The evaluation session was held in the facilities of Institute of Electronics and Telematics Engi-neering of Aveiro (IEETA) with the participation of two elderly people and a physiotherapist. The professional was geographically apart from the patients during monitoring of the session. The sample size is justified by the intention to verify the general potential of the service in terms of layout, usability and satisfaction in a small and controlled group of potential end users.

In this first evaluation, some less stable com-ponents (use of speech in the elderly user appli-cation and system logging) were not included, but all other previously mentioned components were available.

Participants interacted with the service ho-listically, conducting part of an exercise session monitored by health professionals, such as physio-therapists. A small set of tasks (physical exercises) were defined based on the scenarios created for requirement analysis. Each user session begins with a brief explanation of the objectives of the session, the operation of the service, and the tasks and scenes to perform next. Then, a description of the tasks the user should perform was delivered. In order to test the multimodality of the service, during the session, users were induced to try the different input and output modalities.

During each session, evaluation aimed subject’s participation, the pace of activities, use of resourc-es and identification of missing functionalities. Data collection on these subjects was achieved by recording critical incidents (in loco) and, at the end of the session, by answering a question-naire (post-evaluation). The service assessment questionnaire assesses: graphic user interface (layout), usability and satisfaction. Regarding layout evaluation, assessment contemplates three

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major areas of the graphic user interface: monitor-ing, reception of information and user input areas. In terms of usability, the suitability of input and output devices were evaluated (ex: interaction via touch is a facilitator or a barrier). Regarding satisfaction, session, motivation and expectations were contemplated (e.g.: is interaction with the system pleasant?)

Each evaluation session took about 25 minutes: evaluation during the session took 10 minutes and post-evaluation another 15 minutes.

Results

Regarding positive aspects, participants were satis-fied with how the session went, namely because they managed to accomplish the physiotherapist’s indications and felt comfortable interacting with the service. Both users reported being receptive to the use of such a service at home, obviously when fully developed. The graphic arrangement of different components was a facilitator for both users. However, adjustments were suggested, for example: to focus more on the information com-ponent from the health professional; create more meaningful commands and represent them with icons; reduce the monitoring area on the interface. Despite complaints about font size, participants indicated exercise presentation (including written statement and representative image) as a facilita-tor to their execution. Also, interaction by touch, although rarely used during the sessions, was a highly valued aspect.

The negative aspects mentioned by the elderly users were: the absence of speech input capabili-ties; the mirrored video image; the fact that the images included in the health professional’s indi-cations did not include motion; and some buttons were too small. They also mentioned that the font size was suitable for sitting in front of the screen but too small when doing the exercises.

As a final comment, both elderly people reported the potential and importance of the existence of this

CONCLUSION

In this chapter, we present the description of a new service in the area of elderly health support at home. Driven by the possibility of offering technological solutions that can facilitate the daily life of the elderly, increasing their pro-activity, the proposed service assumes itself as a telerehabilita-tion system with the main objective of increasing the elderly’s work capacity and autonomy.

Based on a modern architecture, which allows high modularity and integration rates, the service allows health professionals to perform a complete rehabilitation session with complete control over the patient. Specification of exercises, constant feedback and video support are some of the sup-ported features.

On the patient side, value comes from the possibility of performing common routines in the comfort of their own home and with proper supervision. Powered by AdaptO, applications gain adaptability in terms of interface capabilities through dynamic user and context modelling, thus facilitating interaction and patient comprehension.

Although results are only available for a re-duced number of users (considered by the authors to be adequate for this stage of development) and obviously not conclusive, they provided impor-tant cues about the positive and negative aspects of the telerehabilitation service and prototype in development. As part of the adopted development methodology, new evaluations will be made after successive refinements of the service components and applications, involving a higher number of end users.

Many of the participants’ criticisms will be rectified in the future. As the prototype is still at a developmental phase, some features are not yet completely operational (e.g.: speech modality) or were not adequately explored in the applications used during the first evaluation (e.g.: the possibil-ity of text size adaptation depending on the user’s distance from the screen).

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The fact that the participants’ criticisms and suggestions correspond in general to the short-term work scheduled for this project is also a relevant result. As the main goal is the creation of a usable, accessible and interesting service, they provide some assurance that the development team is in tune with users’ expectations and needs.

FUTURE RESEARCH DIRECTIONS

The service being at a prototype stage, many di-rections can and should be explored in the future. A few are presented next.

Improvements to Output Adaptation: Ongoing and future work includes: improving adaptation heuristics; use of more advanced user models; tests with elderly users (the target for our work); learning from user related information (prefer-ences and history of usage); creating new output agents such as 3D dynamic graphics and avatars.

Improved Presentation of Exercises: One issue when creating a telerehabilitation project is how to present the exercises to the patients. Given that textual information is not very explicit, a better alternative is to record exercises and show them to the patient as the session progresses. While this procedure may be the most accurate one, it also raises a few issues.

The first is related to the need to record all pos-sible exercises prior to use of the system. While a given subset of exercises maybe considered simple to record, the number of possible exercises in a rehabilitation system is high, work methodologies differ according to the health professional; and if during a session a physiotherapist wants a patient to perform a given exercise a little differently, no visual information will be available.

A possible solution for these issues would be the creation of a module capable of driving a 3D avatar with textual information describing the exercises to show how to perform them. Each exercise would be described by a combination of movements and later synthesized in three dimensions.

Explore Sensors to Automate Alerts and Pro-vide Evaluation Information: The sensors that presently capture data at the elderly’s location (surface electromyography sensor, video camera and Microsoft Kinect) offer great potential to provide additional information to both types of end-users of the service. With further processing it would be possible to generate alerts regarding incorrect execution of exercise steps or even detect more problematic abnormal situations such as too high a cardiac rhythm. Quantitative evaluation can be also provided to be displayed on the elderly and health professional applications. Particularly appealing is the exploration of Kinect in this context, mainly due to the conjunction between an in-depth sensor and a high resolution camera resulting in possible implementations of new im-age recognition algorithms at much higher speed rates. Kinect could support detection of abnormal situations, such as falls or incorrect procedures. When detected, the system would alert the phys-iotherapist, requesting his attention. In addition, Kinect has the potential to be used as an evaluator for the exercises by recording them, extracting relevant information about the user’s posture evo-lution in time and comparing with stored correct executions. With this, exercises could be scored, allowing for easier evaluation of the treatment by health professionals.

Extend the Service to Enable a Distributed Class: A possible natural extension to the service described would be to establish a group rehabilita-tion service. This rehabilitation approach could be distinguished from others by its special focus on group physiotherapy. Different alternatives for group control could be implemented and explored. As an example, each participant would only progress to the next exercise on the work plan when all others had finished the exercise. Consensus and leader election algorithms could be used within the scope of the service. At the end of the session, results from all the remote group members would be collected and sent to the health professional to help him understand the evolution of the treatments.

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ACKNOWLEDGMENT

This work is part of the COMPETE - Programa Operacional Factores de Competitividade and the European Union (FEDER) under QREN Living Usability Lab for Next Generation Networks (http://www.livinglab.pt/).

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KEY TERMS AND DEFINITIONS

Active Aging: Is the process of optimizing op-portunities for health, participation, and security in order to enhance quality of life as people age (WHO, 2002).

AMITUDE: Is a generic model of use and presents the aspects: Application type, Interaction, Task, other activity, domain, User, and Environ-ment of use.

Cloud Computing: Is a model for enabling convenient, on-demand network access to shared computing resources (such as servers, storage, applications, and services) that can be rapidly provisioned and released with minimal manage-ment effort or service provider interaction. It is this concept that is generalized in Cloud Rehabilitation.

Multimodality: A modality, or, more explic-itly, a modality of information representation, is a way of representing information in some medium (Bernsen & Dybkjaer, 2009). By defini-tion, a multimodal interactive system uses at least two different modalities for input and/or output. Multimodality allows an integrated use of various forms of interaction simultaneously.

Persona: A persona, adopting the definition by (Blomkvist, 2002), is a model of a user that focuses on the individual’s goals when using an artefact. The model has a specific purpose as a tool for software and product design. It is an archetypical representation of real or potential users, not a description of a real, single user or an average user. The persona represents patterns of users’ behaviour, goals and motives, compiled in a fictional description of a single individual. It also contains made-up personal details, in order to make the persona more “tangible and alive” for the development team. The idea of personas originated from Alan Cooper, an interaction de-signer and consultant (see Cooper, 1999).

Rehabilitation: Rehabilitation aims at en-abling individuals to reach and maintain an optimal physical, sensory, intellectual, psychological, and social functional level (WHO; http://www.who.int/topics/rehabilitation/en/).

Telerehabilitation: Is the use of electronic communication and information technologies to provide rehabilitation at a distance.

Treatment Effectiveness: Evaluation un-dertaken to assess the results or consequences of management and procedures used in combating disease.

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