AGATHE : A tool for personalized rehabilitation of cognitive functions based on simulated activities of daily living

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Evelyne KLINGER, Abdelmajid KADRI, Eric SORITA, Jean-Luc LE GUIET, Pauline COIGNARD, Philippe FUCHS, Laure LEROY, Nicolas DU LAC, Fabrice SERVANT, PierreAlain JOSEPH -AGATHE : A tool for personalized rehabilitation of cognitive functions based on simulated activities of daily living - IRBM - Vol. 34, n°2, p.113-118 - 2013

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AGATHE:

A

tool

for

personalized

rehabilitation

of

cognitive

functions

based

on

simulated

activities

of

daily

living

E. Klinger

a,∗

_,

_A.

_Kadri

a

_,

_E.

_Sorita

b

_,

_J.-L.

_Le

_Guiet

c

_,

_P.

_Coignard

c

_,

_P.

_Fuchs

d

_,

_L.

_Leroy

d

_,

N. du

Lac

e

,

F. Servant

f

,

P.-A.

Joseph

b

a_LAMPA,_EA_1427,_arts_et_métiers_ParisTech,_2,_boulevard_du_Ronceray,_BP_93525,₄₉₀₃₅_Angers_cedex_01,_France b_EA_4136,_CHU_de_Bordeaux_Pellegrin,_SMPR_Tastet_Girard,_place_{Amélie-Raba-Léon,}₃₃₀₇₆_Bordeaux_cedex,_France

c_CMRRF_Kerpape,_BP78,₅₆₂₇₅_Ploemeur_cedex,_France

d_Centre_de_robotique,_Mines_ParisTech,_60,_boulevard_{Saint-Michel,}₇₅₂₇₂_Paris_cedex_06,_France e_Intempora,_2,_place_{Jules-Gévelot,}₉₂₁₃₀_{Issy-les-Moulineaux,}_France

f_Dassault_Systèmes,_10,_rue_Marcel_Dassault,₇₈₉₄₆_{Vélizy-Villacoublay}_cedex,_France

Received11January2013;receivedinrevisedform15January2013;accepted15January2013 Availableonline16March2013

Abstract

Everyyear,tensofthousandsofpeoplefallvictimtooneofinvalidatingneurologicalpathologies.Acquiredbraininjuryleadstocognitive impairmentandheavylossofautonomy.RehabilitationinterventionsareneededtoenablepeopletorecovercapacityandreturntoInstrumental ActivitiesofDailyLiving(iADL),suchasgroceryshopping.Unfortunately,theresourcesmadeavailableincognitiverehabilitationareinsufficient forthegrowingneedsofvictimsofbraindamage.ThegoaloftheAGATHEprojectistodevelopatoolthatwillprovidetherapistswithan innovativemeansofdealingwithcognitiverehabilitationandofferpatientscustomizedrehabilitationsessions,onthebasisofsimulatediADL. AGATHEfitsintoaccessibilityprospectsofthetool(foreveryone,everywhereandanywhere)andreductionofthecostofrehabilitation.AGATHE allowsthestrengtheninganddiversificationofskillsandexpertiseoftheproject’sclinicalandresearchpartnersaswellastheopeningofanew applicationfieldtothetechnologyoftheindustrialpartners.InitialtestsoftheAGATHEtoolhavebeenperformedamongtherapistsandpatients afterbraininjuryinordertovalidateusabilityissues.Perspectiveofefficacytrialshasbeenidentifiedanddevelopmentprojectsareexplored. ©2013PublishedbyElsevierMassonSAS.

1. Introduction

Cognitiveimpairmentsareamajorfactoroflossof auton-omyanddependence.InFrance,foranewgenerationofadults aged 20 to 60 years, nearly 13% of people willbe affected ofmentaland cognitive impairment beforethe ageof retire-mentfromprofessionalactivity[1].Theincidenceofcognitive deficitsincreasesbeyond60yearswiththeimpactof degenera-tive[2]andvascularbraindisorders.EachyearinFrance,despite theimpactofroadsafetyprograms,morethan25,000people, mostlyyoungadultsbetween15and25years,sufferfrom cog-nitiveimpairmentresultingfromTraumaticBrainInjury(TBI), especially aftera road accident [3]. Atthe sametime, more than130,000peoplesufferadisablingstroke[4].Rehabilitation

∗_{Corresponding} _author. _Arts _et _Métiers _ParisTech, _LAMPA, _4, _rue _de

l’Ermitage,53000Laval,France.

E-mailaddress:evelyne.klinger@ensam.eu(E.Klinger).

interventionsareneededtoenablethesepeopletorecover capac-ityandreturntoinstrumentalActivitiesofDailyLiving(iADL), suchasgrocery shopping.Unfortunately, theyaredifficultto carryoutandoftenbelowtheexpectedefficacy.

Rehabilitationisaglobalprocesswithsequencesof assess-ment and rehabilitation steps [5]. Traditional rehabilitation methodsleanonananalysisofthedeficitsand/oronaprolonged confrontation to daily living situations. If the individualized methodsarethemost appropriate[6,7],theyareexpensive to performandtimeconsuming.Toomanypatientsareexcluded fromtheaccesstocare.Itisthusnecessarytofindadaptedand configurabletoolsthatcanbeusedbyanyoneandmoreoften, indifferentplaces,suchasrehabilitationcenters,medical prac-ticesor at home.Theassets of virtualreality to addressthis bigproblemofpublichealtharetodayscientificallyrecognized [8].So, based onimmersion within virtual environmentsfor activitiesofdailyliving,our approachtakesplaceinthe per-spectiveoffunctionalcapacitiesrehabilitationanddependence reduction.

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TheAGATHEproject(Adaptable,configurableand upgrad-able tool for the generation of individualized therapeutic applicationsincognitive rehabilitation,2009–2012)1was cre-atedin anattempttoaddresssomeoftheseissues.AGATHE ispositionedasanindustrialresearchprojectthatoffersanew fieldof applicationofthetechnologies of theindustrial part-ners.Itsfinalityistheintegrationofnewhabitsinthetherapeutic practicetodiversifythepropositionsofinterventionincognitive impairmentsrehabilitation.Therapistswillseetheirintervention facilitatedbythestrategiesproposedbyAGATHEforpatient’s progress,aidstosuccessinthetask,cooperationandtherapeutic intensification.

2. StateofArt

Virtual Reality (VR) offers human-computer interaction paradigminwhichusersarenolongersimplyexternalobservers ofimagesonacomputerscreenbutareactiveparticipantswithin a computer-generated virtual world. VR provides interactive functionalsimulationswithmultimodalfeedback,task gradua-tionandreviewofperformancethankstovariousrecordeddata. Overthepastdecade,therapiddevelopmentofVR-based tech-nologieshasbeenbothanassetandachallengeforassessment andrehabilitation[9–11].VRallowstheclinicianstoimmerse thepatientinaspatialandtemporalcontextdifficulttoprovide viaconventionaltherapy inordertocreateinnovative clinical paradigmsofrehabilitation.Moreover,VRincreasespatient’s motivationtotrainthankstogamingaspects.

Inneuropsychology,studieswerecarriedouttoexplorethe potentialofVRinvariouscasesofcognitiveimpairment: atten-tion[12],executivefunctions[8],memory[11],orvisuospatial abilities.Someapplications arealso dedicatedtoactivitiesof dailylivinginfamiliarplacesinordertotrainthepatientsbefore theycomebackhome.Studiesshowedthatvirtualtrainingwas foundtotransfertorealtaskperformance[13,14].

Activitiesofdailylife,whicharethecoreoftheAGATHE project,allowthetherapiststoassessthepatientaccordingto var-iouscognitivecomponents(e.g.,executivefunctions,memory, attention), aswell asin aglobal functionalapproach. Gener-ally,theVR-basedactivitiesaretakingplaceinvirtualkitchens [15–17],orinvirtualsupermarkets[18,19],thechoiceofthetask andthequalityofinteractionbetweenthesubjectandthe vir-tualworldbeingcrucial.InFrance,theVirtualActionPlanning Supermarket (VAP-S)was designedtoassessexecutive func-tionsandresultsamongvariouspopulations(ParkinsonDisease, stroke,ormildcognitiveimpairment)confirmeditsfeasibility anditsdiscriminativepotential[20–22].Studiesarecurrently carriedouttotesttherehabilitationassetsininstrumental activ-itiesofdailylivingduringagraduatedshoppingtaskwithinthe VAP-S.

Theobservationofpatientbehaviorandactivitythanksto var-iousrecordeddata(likethevariouspatient’sactionsintheVR scene,butalsovideoandaudio,eye-tracking,motioncapture, orphysiologicalmeasurements)andthecorrespondingplayback

1 _{www.agathe-rv.net}_.

capabilities,arenecessaryforperformancereviewand construc-tionof adapted interventions. In fact, the tasksin whichthe patientis involved allow clinicians to collect detailed infor-mation about the process of patientperformance rather than focusingprimarilyonafinalproduct,likeascore.Consequently, thereal-time acquisitionandanalysisofpatientdataare fun-damental.Allthepossibilitiesofphysiologicalandbehavioral measuresinavirtualenvironmentalsoprovidenew opportuni-tiesfortheinvestigationofhumanbehaviorandperformance [23].

TheuseofVRforcognitiveinterventionisstillatthestage ofexploratoryresearchwithprototypesalthoughanumber of singlecasestudies, groupcomparisons and evenrandomized clinicaltrialsarenowunderway.ApplicationofVRfor health-careisexpectedtocontinuetogrowduetotheunanimousand urgentneed forimproved assessmentandrehabilitation tools [24].TheAGATHEprojectwascreatedtobringananswerto thisneed andtoprovidea widerangeofsimulated iADLfor cognitiverehabilitation.

3. AGATHEprojectoverview 3.1. Objectives

AGATHEobjectiveis,atfirst,toprovidetherapistswithan innovativemeansofdealingwithcognitiverehabilitationandto offerpatientscustomizedrehabilitationsessions,onthebasisof simulatedactivitiesofdailyliving.Thenitistofitinto acces-sibility prospects of the tool (for everyone, everywhere and anywhere)andreductionofthecostofrehabilitation.AGATHE aimsatthestrengtheninganddiversificationofskillsand exper-tiseof the project’s clinicaland research partners as well as theopeningofanewapplicationfieldtothetechnologyofthe industrialpartners.

3.2. Consortium

AGATHE project is an industrial project that was con-ceivedandcoordinatedbyArtsetMétiersParisTech,duetothe expertiseofthisprojectleaderinvirtualrealitytherapeutic appli-cations.So,sixpartnerswithcomplementarymultidisciplinary skills worked together to design and produce the AGATHE tool.TheResearchTeamincludedpartnersfromArtsetMétiers ParisTechand fromArmines, bothspecialists invirtual real-ityanditschallenges.TheHealthTeamincludedtheBordeaux EA4136and theKerpaperehabilitation center,featuring spe-cialistslikerehabilitationclinicians,occupationaltherapistsand neuropsychologists.TheIndustrialTeamincludedtwosoftware publishers;DassaultSystèmesandIntempora.

3.3. Participants

We choseto buildthe AGATHEproject in thecontext of acquired braininjury, especially in the contextof Traumatic BrainInjury(TBI)andstroke.Patientsandtherapistswho partic-ipatedinthepilottestswererecruitedintherehabilitationservice

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Fig.1.AGATHE(Adaptable,configurableandupgradabletoolforthegenerationofindividualizedtherapeuticapplicationsincognitiverehabilitation)functional approach.

of theUniversity Hospital of Bordeaux and that of Kerpape rehabilitationcenter.

3.4. Method

AGATHEtoolisasoftwarepackagededicatedtotwotypes ofusers (patientsand therapists)andbased ontworeal-time softwares3DVIAStudiofromDassaultSystemes(creationof real-timevirtual interactiveenvironments) andRTMapsfrom Intempora(monitoringandreal-timerecordingofpatient activ-ity through sensors). AGATHE tool isa Virtual Therapeutic Application(VTA)leaningonthedesignofVirtual Therapeu-ticScenarios(VTS)thatarecanvasofpredeterminedtasksfor therapeuticpurposes.

Thescientificandtechnicalworkwasbasedonthe arrange-ment of AGATHE tool in users views, corresponding to functionalblocksandtothefivestagesthroughwhichthepatient andthetherapistwillusethetool:

• welcomeandassessmentofthepatient; • designoftheVTSbythetherapist;

• therapeuticsessionwithintheVTSforthepatient;

• supervisionofthepatient’sactivityandmanagementofthe VTSbythetherapist;

• analysisofpatient’sactivitybythetherapist(Fig.1). Thisworkwascarriedoutaccordingtothestepsdescribed below.

3.4.1. Co-Design

Weadoptedaco-designapproach,whichinvolvedthewhole partners. Thanks to the observation of cognitive rehabilita-tion sessions and to brain storming meetings, we collected andsynthesizedtheneedsandpracticesoftherapistsworking

inrehabilitation(physicians,neuropsychologists,occupational therapists).Thedesigners built smallVR experiences forthe therapistsinordertomakeconcretesomeproposals, commu-nicatewiththetherapists,andcollecttheirfeedback.Allthis approachallowedustodrawacommonthread,whichservedas basisforthedesignofAGATHEtool.Foreachusersviews,the collaborativeworkbetweencareexperts(researchersand thera-pists)andtechnicalexperts(researchersandindustrial)enabled to express thefunctionalrequirements, to establishthe inter-connectionsbetweenthefivemodulesandtorefinetheusage scenarios,whichensurethevalidityofthetool.

3.4.2. Researchactions

Thefirststepofthescientificandclinicalprogramwasthe definitionofsequencesoftherapeuticactivitiesbasedondata acquiredbyconventional programsandinitialexperiences of interventionssupported byvirtual reality.Appropriate means offacilitationandincreaseindifficultyofthetaskshadtobe established.

Oneofourmaintaskswastoprovideacleardescriptionofthe chosentasks(topographictasks,postmail,groceryshopping)in ordertomodelthemandtoimplementthem.Usingmindmaps wedescribedthetaskinagenericwayaccordingtothefollowing components:setting, instructionsandsteps.Weidentifiedthe criticalstepsintheVTSwithfactorsofsuccessorfailure,and weextractedvarioustherapeuticindicatorsfromthetasks.

WhenauserinteractswithaVRsystem,alotofinformation isdeliveredtotheuserwhosecharacteristicsmustbeadaptedin ordertobeusefultothepatient.Duringsmalltrialsweexplored someofthose characteristicslikethePhysical Fieldof View (PFOV:theanglesustendedbythedisplaydeviceandtheuser’s retina)andtheSoftwareFieldofView(SFOV:FieldofView of the virtual camera), that are two fundamental parameters inVR-basedexperiences[25].Someothertrialsallowedusto

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Fig.2.AGATHEneighborhoodandpatientpointofview.

testVRinterfaces(gamepad,Kinect)andtodefinenavigation parameters,likepointofview(firstorthirdperson).

3.4.3. Tooldevelopment

WefocusedoureffortsonthedevelopmentofAGATHEcore forfirstuseclosetothepatientsincarecenters.Thiscoreleanson avirtualneighbourhoodwherefunctionalplaceswerepositioned (town,studio,postoffice,supermarket)(Fig.2).Eachfunctional placeisconducivetofunctionaltasksorspecificiADL (topo-graphictasks,postmail,shopping...).DuringthevirtualiADL (vADL),theparticipant’sactivityismeasuredthrough indica-torsthatcanbeeithergenericandthereforecommontoalltasks, suchassessionlength,orspecifictothetask,asthetimeina crossroadsforatasktopographic.

Thiscorewasbuilttobescalableandaccepttheadditionof furthermodules:newvADLsinexistingplaces,newplaceswith functionaltasksandspecificindicators.Itcanrecordallpatient’s activityandreplayitinreal-timeordelayed.Itwasalsobuilt tofollowthepatient’sclinicalpathwaywhichincludesvarious phases:

• testofabilities(toassessthecapacitiesofthepatientto suc-cessinnavigatingandinteractingwithinvirtualworlds); • familiarization (toinformand trainthepatientabout basic

meansofinteractioninAGATHEtasks);

• evaluation (prototypical tasks to assess the status and the progressofthepatient)and;

• rehabilitationinterventions(customizedtasksadaptedtothe patient’scapacitiesandneeds,andtothetherapistobjective). AGATHEcorereliesonthreesoftware:3DVIAStudioforthe creationofthevirtualentities,theimplementationofthe behav-iors andtasks andtherenderingduring thepatient’s session, RTMapsforreal-timecaptureofpatient’sactivity,andAcapela fororalisationoftheinstructionsanddialogues.

GraphicalUserInterfaces(GUI)havebeendevelopedaround AGATHEcore.TherapistGUIincludesafirstGUIforsetting

Fig.3.TherapistGraphicalUserInterfaces(GUI)forsettingthetask.

thetasks,managing theinstructionsandtheaids thatwillbe deliveredtothepatientduringthesession,andasecondGUIfor real-timesupervisionofpatient’sactivity,or delayedanalysis andreplayofpatient’s activity(Fig.3). PatientGUIincludes twomainspaces: topscreen isdedicated to toolspotentially usefultocarryoutthetaskandlinkedtospecificinformation (pause,planoftheneighbourhood,instruction,help,dateand time)(Fig.2).

Allthesesoftwaremodulesweredeliveredtothepartnersin successivebetaversionsthathavebeensetupinthe rehabilita-tionservicesofBordeauxandKerpape.

3.4.4. Pilottrials

Duringthedevelopmentofthetool,preliminarytestswere conductedusingthe navigationexercise,thatisa component

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Fig.4.Patientinteractingduringatherapeuticsession.

oftheaptitudetests. Theobjectivewas todefinetheoptimal settingsfortheuserpointofview,theSFOV,thelocomotionand rotationspeedsduringvisualscanning,andtounderstandhow theuserestimates thedistanceswithsuchparametersvalues. Thesesettingsarefundamentaltothesuccessfulcompletionof tasksthatareavailabletopatients.

Two protocols (P1:therapists andP2: patients) havebeen establishedtocarryoutpilotteststoevaluatethefeasibilityand usabilityofthetoolAGATHEwithtwotypesofendusers. Pro-tocolP1 was conductedwith participantsplayingtherole of therapistandProtocolP2wasconductedwithhealthysubjects playingtheroleofpatientsandthenwithstrokepatients. Dur-ingprotocol P2,participants hadto achievetheaptitudetest, thefamiliarization taskandtwofurtherclinicaltasks,a topo-graphicalorientationtaskinthevirtualdistrictandanexecutive task,namelythemailingtask.Questionnairesspecifictoeach protocolwerecreatedtoanswerquestionsforthevalidationof thetool. P1-Questionnairescollectqualitativefeedbackabout theusabilityofthetherapistGUI(e.g.launchingthesoftware, choiceandsettingofthetask).P2-Questionnairescollect qual-itativeand quantitativefeedbacks about usability ofpatient’s GUI,VR contents,orVR interfaces.Anadditional question-naireallowedustocollectthefeedbackofthetherapistsabout theclinicaloutcomesextractedfromthedatarecordedalongthe session.

4. AGATHEprojectresults

Allthecomponents andfunctionalities weretested during the pilot trials and we collected the feedback of about 15 therapists (physicians, occupational therapists, speech thera-pists,neuropsychologists) and13patients afterstroke.These feedbackscontributedtotheiterativeprocessoftestsand devel-opment.Therapistssucceededincustomizingtheexperienceto matchpatientfunctioningandneeds,andtograduallystimulate recoveryofabilities.Patientswillinglyinvestedintheattractive andrewardingrehabilitationtasks.

Finally, the first AGATHE prototype operates on a PC equippedwith agood graphiccard,twoscreens(one forthe patient and one for the therapist), a webcam, and the three

necessary softwares: 3DVIA Studio, RTMaps and Acapela. NavigationandinteractionduringthevADLarepossiblewith variousinterfaces(e.g.,mouse,keyboard,gamepad)(Fig.4).

Inordertoguaranteeonthesuccessandonthewide distribu-tionofAGATHE,acompanyisbeingsetuptocommercialize AGATHE tool. Synergies between the partners will be sus-tainedthroughclinicalresearch(efficacytrials)anddevelopment projectsofnewfeatures.

5. Conclusion

WithAGATHE,virtualrealityservescognitivetherapies,by offeringpatientscustomizedrehabilitationsessions,onthebasis ofsimulatedactivitiesofdailyliving,andbyallowingtherapists tomeasurepatientactivityandtofollow-uphisprogress.With AGATHE,patientsbecomeactorsoftheirtherapy.

AGATHEtoolisnowexisting;preliminarydatahavebeen obtained during the pilot studies. Next steps will consist in consolidatingthecurrentprototypeandincreasingits function-alities, as well as assessing the efficacy of AGATHE-based rehabilitationamongvariouspopulationsofpatients.

Acknowledgement

ThisworkwassupportedbytheFrenchNationalResearch Agency(ANR)throughTheTecSanprogram(projectAGATHE ANR-09-TECS-002).TheAGATHEprojectwascertifiedbythe ImagesetRéseauxclusterin2009.WethankLavalauthorities (LavalAgglomérationandConseilGénéraldelaMayenne)for theirfinancial supportto the Arts et Métiers ParisTech team duringtheAGATHEproject.

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