Telematic Rehabilitation 2.0Kai-Uwe Hinderer and Petra Friedrich, Kempten University of Applied Sciences

Kempten, Germany, kai-uwe.hinderer@fh-kempten.de

Otto Hobel, medica Medizintechnik GmbHHochdorf, Germany

Bernhard Wolf, Heinz Nixdorf-Lehrstuhl fur Medizinische Elektronik, Technische UniversitatMunchen

Munich, Germany

Abstract—Today, the compliance of device-basedtherapy for extended periods lies often below 50 percent[1]. Furthermore every second household is equippedwith both a powerful computer and a flat-screen TV([3], [4]). This project is motivated by the idea toconnect these facts.For an increased motivation to use the daily hours ofmedia consumption simultaneously for rehabilitation,a data animation is combined with a browser windowor media player. With the COMES R©1 interface, atherapist has additionally the possibility to interactwith the user and animation. Moreover a usabilitytest has been made, to examine the acceptance ofboth patients and therapists for a media supportedrehabilitation.The objective of this project is to reduce the motiva-tional threshold of a daily training and thus increasethe compliance in long term rehabilitation.

Index Terms—Personalized Medicine, TelemedicalAssistance-System, Telemedical exerciser, Bluetooth,Animation.

I. INTRODUCTION

OVER the last years the telematic rehabilitation

experiences a steady increase. A wide variety of

products for monitoring all kinds of vital parameters

is available on the market. Apps for tablet PCs and

smart phones provide a steady data flow updating the

user’s current health status 24/7. With all these smart

products on offer, it is supposedly easy to treat or

rehabilitate yourself. With this development however,

misdiagnosis and incorrect behavior are inevitable.

1COMES R©: ”Cognitive Medizinische Systeme” is a develop-ment of the Heinz Nixdorf-Lehrstuhl fur Medizinische Elektronikof the Technische Universitat Munchen and is a registered trade-mark. (http://www.comes-care.net/)

For this reason, a holistic approach is pursued in

this joint project2, which includes the therapist in the

self-directed rehabilitation. Especially in the decisive

phase of long-term rehabilitation, the months after

a stay in a rehab clinic, this therapeutic support is

extremely important. In order to achieve this, modern

ways of communication need to be used. Therefore

this project takes advantage of the possibilities new

technology and networking create, to maximize the

benefit for the user.

In particular, this article deals with the telematic re-

habilitation of cardiovascular diseases and limitations

of the lower musculoskeletal system with the help

of graphical analysis of live training data. Both to

increase compliance in the post-rehabilitation phase

as well as the motivation for self-directed training at

home was the goal of a preliminary approach [2].

These goals are pursued further, but in a modular

and independent way, to meet the challenges of a

rapidly changing sector. This means a solution has

been created, which places the emphasis on the user

benefit and is independent from both the terminal

and the training device. Moreover a usability-test has

been launched to investigate the acceptance of this

animation and entertainment supported rehabilitation.

It aims on getting a more precise idea of the needs

and challenges concerning both the therapist as well

as the user.

The prerequisites for the use of this technology is

only a Bluetooth-enabled training device that is able

to send live data, as well as a displaying terminal

device, which likewise is equipped with a Bluetooth

2Partners: Kempten University of Applied Sciences, HeinzNixdorf-Lehrstuhl fur Medizinische Elektronik of the TechnischeUniversitat Munchen and the medica Medizintechnik GmbH

978-1-4799-1412-8/13/$31.00 ©2013 IEEE

2013 IEEE Third International Conference on Consumer Electronics - Berlin (ICCE-Berlin)

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Fig. 1. Animation structure

interface and can access the Internet. In this case,

an application will be presented, which follows this

modular approach and shows a live-animation of a

cardio training on a telematic rehabilitation device3.

To realize the idea of increasing the motivation to

use the daily hours of media consumption4 simul-

taneously for rehabilitation, both the animation and

arbitrary web content are displayed on a smart TV.

The objective of this project is to reduce the motiva-

tional threshold of a daily training and thus increase

the compliance in long term rehabilitation, to help

the user realizing the importance of this training

and supporting him or her therapeutically via the

COMES R© platform5.

II. CONCEPT AND REALIZATION

Based on preliminary work [2] a modular tech-

nical concept was developed in the newly equipped

AAL-laboratory at Kempten University of Applied

Sciences. This approach intends to create the possi-

bility of an easy individualization of the implemented

elements, the user interface as well as the displaying

hardware. Therefore the process had to be decom-

posed in the individual steps, which are:

1) receive and forward live data

2) display data and generate live feedback

3) long term feedback with COMES R©

To complete this approach the individual steps

were combined to flexible modules. Thereby, partic-

ular attention was paid to keep the module interfaces

as simple as possible, making the adaption to the

3The Thera-vital exerciser of the medica Medizintechnik GmbHis a accredited medical device after EU definition. Both active andmotor supported passive training is possible with this device.

4In Germany the average time in front of the TV lies atapproximately 224 minutes per day per person [3]

5In COMES R© mobile measured vital parameters are intelli-gently evaluated by an expert system before they are provided tothe user along with medical information and trends.

Fig. 2. Animation and Media content during a training

changing challenges of individualized rehabilitation

easily realizable.

To achieve a modular solution, the data handling and

interpretation had to be implemented in a way to

minimize the dependencies to the operating system of

a device. Furthermore the modularity was extended

to the design of the user interface and animation.

A. Material and Methods

To realize a solution that inter-operates on multiple

platforms, that is able to access the system resources

and entails great flexibility a programming language

had to be found, which matches these requirements.

Therefore the choice met the Qt-Framework in com-

bination with C++. This choice was assured, because

of the inclusion of QML (Qt Meta Language)6 that

supports JavaScript combined with dynamic property

bindings. Since Qt does not fully support Bluetooth

yet, the wireless data handling was implemented in

python 2.7 with the Bluetooth-library PyBluez7. Here

as well, the idea of flexibility and modularity was

matched perfectly by the properties of this program-

ming language.

For the devices the initial development targets were

personal computers running Microsoft R© Windows as

well as the Raspberry Pi8 running Debian Linux. With

covering Windows and Linux the user is given the

chance to either use existing hardware or choose from

6QML is a declarative language that allows user interfacesto be described in terms of their visual components and howthey interact and relate with one another (http://qt-project.org/doc/qt-5.0/qtquick/qtquick-applicationdevelopers.html)

7Python: http://www.python.org/ - PyBluez: http://code.google.com/p/pybluez/

8The Raspberry Pi is a credit-card-sized single-board computerdeveloped in the UK - http://www.ADpi.org/

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Fig. 3. Sprite for the player animation.

a large selection of devices. Moreover by using the

RaspberryPi, every HDMI-ready device, like TV or

computer monitor can be used as displaying back-end

for this media supported rehabilitation.

B. Interface

The interface for the intermodular communication

was chosen to be the local TCP-port. Since this socket

is fully supported by the used languages, is straight

forward in its implementation and shows good per-

formance in forwarding the data, communication over

the TCP-port seems to be perfect for this project.

For its high security level and flexible application the

XML-based SOAP network protocol9 is used for the

web-communication.

As wireless interface the use of the Bluetooth R©

technology was continued. The choice was encour-

aged through the ongoing significant support of

tablets, smart-phones or personal computers. Further

the newly developed Bluetooth R© low energy profile

indicates a long-term presence of this technology with

great potential in the wireless communication.

C. Intelligence, Design and Feedback

Through the support of JavaScript the whole

engine was written in QML and JavaSript. This

implies the time synchronization, the scene animation

and the feedback generation. QML provides the

possibility of a direct object manipulation, which

results in slim functions to calculate new positions

and move the opponent objects as well as the

scene objects. Further QML supports transitions on

changing object coordinates, size or shape. Therefore

smooth movements can be created. This impression

9The Simple-Object-Access-Protocol provides a way to com-municate between applications running on different operatingsystems, with different technologies and programming languages.http://www.w3schools.com/soap/soap intro.asp

is completed by fluent sprite animations, which are

newly supported in Qt v5.0.

Supporting the simplicity of the design, the feedback

is intuitively. Two opponents are moved relatively to

the user’s player. Their given speed could be set by

the therapist but could as well be modulated during

the training. The sun, as part of the scene, changes

colors according to the player’s performance and

thereby gives feedback via a traffic light system.

Every frame or timer-tick, the positions of the

opponent’s are compared to the player as well as

the scene-with and screen size. These information

are translated and calculated in an algorithm to

new object coordinates. Depending on the player’s

speed, the opponents move relative to the player.

The displayed parameters like time, speed and

progress are live-parameters from the training

device. They are received over the TCP-port and

form the base for this application. In handling all

device concerned communication over the TCP-port

modularity is achieved. The animation is therefore

only listening on this port and has no knowledge of

the Bluetooth-communication, handled by a small

python-script. On the other hand, this script has no

knowledge of the further use of the data. It just

receives the live-data from the rehabilitation-trainer

over the RFCOMM-protocol, stores the data in a

sqlite-database and forwards it onto the TCP-port.

The training results are both displayed in the

animation context as well as transmitted and put in

a long term context on the COMES R© platform. Here

the user has the possibility to communicate with its

therapist to both discuss the results as well as get

new training tasks. The SOAP-communication is also

handled by the python-script. After the training the

main application sends a signal over the TCP-port

with the ’training-finished’-message. The python-

script then triggers the transmission of the data out

of the sqlite-database, embedded in a XML-file. On

the portal itself all data is collected and can thus

be displayed and reviewed by every user with the

appropriate rights. In addition this platform offers a

holistic overview of diverse health-data, which can

for example be brought into context with each other

to compose a new training [5].

III. USABILITY TEST

To determine the areas for improvement of the

implementation and the general acceptance of this

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multimedia supported training, a small usability test

at the Fachklinik Enzensberg was carried out.

A. Methodology

The test used questionnaires, observation and

interview techniques to gather information about

the subjective impression created by the multimedia

supported training.

Participants: All five patients as well as the

five therapists were experienced with the normal

training on the Thera-vital R© trainer and therefore

needed no introduction concerning the trainer. As

for the visualization, a short introduction was given,

describing the cycling race, the feedback system

and the media content. Some of the participants

were familiar with cycling animations10, but none

had experienced something like the presented

combination.

Setup: Despite of the presence of several rehabil-

itation exercisers at the Fachklinik Enzensberg, only

one could be equipped with an additional monitor and

headphones, linked to a laptop. The media content

was chosen to be an actual episode of the ”Tatort”

TV series. One experimenter observed and provided

assistance when needed.

For the patients the difficulty-level of the two oppos-

ing cyclists was determined after recommendations

of the therapists. The therapists chose their difficulty

arbitraryly.

B. Results and interpretation

For both the five therapists, as well as the five pa-

tients four attributes were examined. On therapeutic

side, these were:

• usability

• motivation

• feedback

• possible fields of application

On patient side:

• intuitiveness

• implementation

• training conditions

• motivation

All participants seemed to enjoy their training and

were very open towards this new technology.

10http://www.tacx.com/

Patients: The intuitiveness of this system was

rated by the patients with top marks. They knew

exactly what to do and why so. Questions and

ambiguities rarely occurred. Only the allocation of

the cyclists to the role of the player or opponent did

not happen intuitively. The training conditions were

also rated high. The installed second screen did not

bother and all of the asked patients agreed, that their

training had been comfortable.

The implementation itself was rated good. The

design was approved and all out of the patients

group liked the live-feedback in form of the cycling

race. The media content did not suit everybody’s

taste. After the patient’s opinions, the concept of a

split-screen is acceptable, but seems not to be the

perfect solution.

The attribute motivation was generally rated high.

For most of the participants the training motivation

increased. Further the idea of a multimedia-supported

training at home, using the available devices, wasn’t

declined at all.

Therapists: The usability and motivational

sector got average grades from the therapists. The

questioned therapists agree in the possibility of an

increased motivation, but are not entirely sure, if

this can be observed in long-term rehabilitation.

However, they can imagine using this system

regularly for their patients. The feedback feature

was rated high. Especially the cycling race with its

adjustable velocities for the opponents was approved

of. The only critical point concerned the adjustment

of the opponents. Here a more complex speed-profile

was proposed.

The areas of application met disagreement. Some

approved of the application at home, some would

rather like to use this system in rehabilitation

centers. Furthermore the telemedical application

of this system, met astonishing approval at the

therapists. Nearly all could imagine evaluating or

setting up cycling therapies for their patients.

All in all the results of this small usability test

are promising and allow the improvement of the

presented application. Moreover a base for further

investigation in form of a case- or usability-study is

formed.

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IV. OUTLOOK

Besides a fully functional data transfer and a fluent

animation the training goals can only be set manually.

Therefore the next step implies the connection to the

COMES R© platform, firstly to simplify the interaction

with the therapist and secondly to automate the

adaption of the training difficulty after the therapists

recommendation. The gathered opinions of patients

and therapists concerning the control, handling and

intuitiveness will be integrated in the final design

and implementation.

Having adapted the resulting sensitive changes

to the application, further analysis can be done.

A case-study concerning the benefit of ’media

and animation supported telematic long-term

rehabilitation in home environment’ shall follow.

Here, the support of the medica MedizintechnikGmbH and its affiliated clinics and physiotherapy

practices like the Fachklinik Enzensberg, will be

very helpful.

Studies have shown, that game supported

rehabilitation has great potential [6]. This in

combination with the telematic rehabilitation in the

home environment bears even greater potential. With

this solution patients should experience their time of

rehabilitation not isolated, but always accompanied

by therapists who care for their health and always

consider the individual weaknesses and strengths.

But this can only be achieved if an acceptance

for new technology on both the patients and the

therapeutic side is established. Concerning the results

of the usability test this has been accomplished.

The therapists however have to have the chance of

earning money with telematic medical care to create

the possibility of ever introducing this technology.

Here health insurance companies and politicians have

to act to meet the challenges of new technology and

the demographic change, which makes telemedicine

inevitable to cover the need for medical care.

Thus as long-term aspiration, an increase of

compliance for the rehabilitation at home and the

usage of new technologies for the user’s benefit are

desirable.

ACKNOWLEDGMENT

The author would like to thank the medica Medi-zintechnik GmbH for their great support. The author

is also grateful to the Heinz Nixdorf-Lehrstuhl fur

Medizinische Elektronik of the Technische UniversitatMunchen including the Heinz Nixdorf Stiftung as

well as the Kempten University of Applied Sciencesthat supported and encouraged this work. Moreover

sincere thanks to the Fachklinik Enzensberg and the

participants in the usability-test, for their support and

help.

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[2] K.-U. Hinderer and P. Friedrich and B. Wolf, Home Care: ATelematic Rehabilitation Exerciser, Consumer Electronics -Berlin (ICCE-Berlin), 2012 IEEE International Conference,pages 15-18, 2012.

[3] Statistisches Bundesamt Statistisches Jahrbuch 2012, https://www.destatis.de/DE/Publikationen/StatistischesJahrbuch/StatistischesJahrbuch2012.pdf? blob=publicationFile,pages 204-208, 2012.

[4] Statistisches Bundesamt 49 % der Privathaushalte habeneinen Flachbildfernseher, https://www.destatis.de/DE/PresseService/Presse/Pressemitteilungen/zdw/2012/PD12018 p002.html, 2012.

[5] P. Friedrich and T. Spittler and J. Clauss and A. Scholz andD Hofsøy and S. Becker and W. Tiedge and S. Tubingerand B. Wolf, Mobile Healthcare - Auf Anruf Arzt (a3), 3.Deutscher AAL-Kongress, Berlin, 2010.

[6] Yong Joo, Loh and Soon Yin, Tjan and Xu, Donald and Thia,Ernest and Pei Fen, Chia and Kuah, Christopher Wee Keongand Kong, Keng-He, A feasibility study using interactivecommercial off-the-shelf computer gaming in upper limb re-habilitation in patients after stroke, Journal of rehabilitationmedicine, Vol. 42, Nr. 5, pages 437-441, 2010.

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