Technology Related Research @ Bruyère Continuing Care

1. Technology Related Research @ Bruyère Continuing Care Frank Knoefel Jeff Jutai Hillel Finestone Bruyere Continuing Care: BIGR Rounds 2012/06/14

2. Objectives • Describe three of the main areas of focus for technology research at Bruyère • Explain how technology can help improve the quality of care at Bruyère and quality of life of patients • Identify opportunities for participating in technology research at Bruyère.

3. OUTLINE • Background • Technology review • Evidence it works • Assistive technology framework • Assistive Technologies Research Lab • Virtual reality in stroke rehabilitation • TAFETA • Nocturia, nutrition, breathing, transfers

4. Aging Population vs. Services • The number of older Canadian adults (65+) is projected to increase from 4.2 million to 9.8 million between 2005 and 2036. • Between 2005 and 2020, the ratio of older Canadians to the labour force (15-64 years) is expected to rise from 25%in 2005 to 52%in 2020 • Aging in Place strategy • Canada will be short +/- 60K FTE RNs by 2022

5. Communication Tech Changes

6. Merchandise Tech Changes

7. Healthcare Tech Changes?

8. Evidence OTN Telehomecare pilot program launched in March 2007 • provides care and monitoring to patients with • congestive heartfailure(CHF) • chronic obstructive pulmonarydisease(COPD) • over 800 patients enrolled • largestTelehomecare program in Canada

9. Evaluation of Telehomecare Program • Evaluated by PriceWaterhouseCoopers through survey tools • Showed reduction of • 65% (avg #) of hospital admissions • 72% (avg #) of ER visits • 95% (avg #) of walk-in clinic visits Ontario Telemedicine Network 2009 Annual Report

11. Gerontechnology Framework

13. At Bruyère Continuing Care, technologies are being researched that address important issues for our patients, such as, computer access, continence management, effectiveness of mobility aids, falls risk assessment, home safety monitoring, recovery following stroke, and support to caregivers.

14. Technology Related Research @ Bruyère Continuing Care Assistive Technologies Research Lab Dr. Jeff Jutai Scientist, Bruyère Research Institute, Professor,Faculty of Health Sciences, University of Ottawa

15. Current Projects • Nouse (nose-as-mouse): Pilot study with stroke patients (funded by BAMO) • Assistive Technology Outcomes Profile for Mobility (ATOP/M) (funded by National Institute on Disability and Rehabilitation Research) • Psychosocial impact of technologies for continence management (C-PIADS project) (funded by CIHR) • A multi-site randomized control trial of the impact of assistive technology with individuals with mobility limitations and their caregivers (CATS project) (funded by CIHR)

16. Nouse Project PI: Hillel Finestone Co-I: Jeff Jutai Co-I: Hilary McKee Co-I: Melanie Carter Co-I: Jodie Taylor Project Co-ordinator: Jasmine Mah

17. Nouse Project (cont’d) The unique, patented technology uses advanced video recognition algorithms to map the movement of the user’s nose to the movement of a computer mouse device thereby allowing a user to operate a computer hands-free. Essentially, Nouse™ is recognized as the first technology to use the nose as the principal feature for facial tracking, a process that involves setting up a webcam on a computer equipped with tracking software. The computer registers an image of your nose and then maps it onto the on-screen cursor, which you control with the movement of your nose. It enables the computer to track movements with dramatically improved precision over traditional methods. Nouse™ application was developed for anybody to use, however, it will be most useful for those computer users who have difficulty using their hands to manipulate a mouse or keyboard, or for those who want to take breaks from using their hands due to fatigue/injury. See a demonstration video of the Nouse at: http://www.nouse.ca/Shop/

18. ATOP/M Project PI: Jeff Jutai Co-Is: Louise Demers (U. de Montreal), Frank DeRuyter (Duke U.), Marcus Fuhrer (NIH), Jim Lenker (SUNY Buffalo) Aim: To investigate user acceptability and clinical efficiency of the ATOP/M

19. ATOP/M Project (cont’d) The Assistive Technology Outcomes Profile for Mobility (ATOP/M) consists of 68 items distributed across two domains, each having two subdomains: Activities (Physical Performance and Instrumental Activities of Daily Living); Participation (Social Role Performance and Discretionary Social Participation). ATOP/M yields two scores, one reflecting respondents’ mobility level while using a device, the other reflecting their capability without it. The ATOP/M has been translated into Canadian-French, and a computer adaptive testing (CAT) has been developed.

20. ATOP/M - Questionnaire The following are example items. Activities Physical Performance: Are you able to get around your neighborhood or town? Instrumental Activities of Daily Living: Are you able to do yard work like raking leaves, weeding, or pushing a lawn mower? Participation Discretionary Social Participation: Are you able to participate in active recreational activities? Social Role Performance: Are you able to go to classes or participate in learning activities? • For the following questions, please use the scale below:5=Without any difficulty; 4=With a little difficulty; 3=With some difficulty; 2=With much difficulty; 1=Unable to do

21. ATOP - Results Results to date: Elderly mobility device users were able to complete the computerized (CAT) version of the ATOP/M within 30 minutes. On average, only 12 items were required to obtain a reliable estimate for each of the with-device and without-device assessments.

22. C-PIADS Project Aim: To measure the impact of continence technologies on the quality of life of elderly individuals Interviews were conducted with elderly individuals who have continence problems and their caregivers. • To identify important areas for impact of continence technologies and what modifications and enhancements might be needed to a self-report questionnaire called the PIADS

23. C-PIADS - Interview Questions What kinds of products are you currently using for bladder and bowel control management? Please describe all of the different types of products you use. What kinds of things do you do to help your bladder and bowel control management? Please describe all of the different things that you do. In a typical day, what kinds of bladder and bowel control difficulties do you have? What things are you able to do with your product(s) that you could not do without it/them? Are you able to do these things by yourself or do you need someone’s help? What impact has your technology had on other people in your life (e.g., family, friends, caregivers, etc.)? What do you like best about your current products and strategies? What positive effects do they have on your life? What do you like least about them? What negative effects do they have on your life? How satisfied are you with your current products and strategies? Take a few moments to think about the technology you want and need most for managing your continence difficulties. Are there any barriers you face when trying to get and use it? Please describe.

24. C-PIADS Project The participants were then asked to look at the Psychosocial Impact of Assistive Devices Scale (PIADS) and say whether they thought it was missing any item that may be important for continence.

25. C-PIADS - Results to Date The PIADS seems to address most of the important psychosocial concerns of adults who have continence difficulties. The development of a modified version for continence (C-PIADS) will require some modifications to the instructions and the addition of some new items which address stigma.

26. CATS Project PIs: Louise Demers (U. de Montreal), Jeff Jutai (BRI), Frank DeRuyter (Duke U.), Ben Mortenson (Simon Fraser U.), Andrew Sixsmith (Simon Fraser U.) Ottawa Site Co-ordinator: Emily Cormier In partnership with the Champlain District Community Care Access Centre. Aim: To investigate an intervention that involves a detailed in-home assessment of the person's current assistive technology and the negotiation and implementation of a personal assistive technology plan with the person and his/her caregiver.

27. CATS Project - Objectives • To determine the efficacy of this intervention for individuals with mobility limitations and for their caregivers. • To explore how the intervention is experienced by these individuals.

28. CATS Project – General Hypotheses We anticipate this intervention will • increase the mobility, well-being, and satisfaction with caregiver assistance of the individuals with mobility limitations; • reduce the amount of caregiver assistance required; and • decrease the psychological demands on caregivers and increase their satisfaction with caregiving-related activities.

29. CATS Project – Methods This project is a multi-site research study. At each of the Montreal, Ottawa and Vancouver sites, we are enrolling 40 individuals with mobility limitations, and 40 of their caregivers (total of 120 dyads). Eligibility criteria: client over 65 years of age, with a physical limitation, no evidence of cognitive deficit, and who lives with a caregiver that offers him/her at least 4 hours of care per week. Participants are assigned to either an immediate intervention group or to a delayed intervention group. Outcomes of this assistive technology treatment for individuals with mobility limitations and their caregivers are measured before and after intervention using a variety of standardized instruments.

30. CATS Project – Anticipated Impact The evidence produced by this study will enable service providers to offer assistive technology interventions that are more attuned to the needs of both individuals with mobility limitations and their caregivers and enable providers to lobby for better funding for equipment and follow-up intervention services.

31. For further information: Dr. Jeff Jutai jjutai@uottawa.ca Research lab located at: Saint-Vincent Hospital, Annex B, 3rd floor Lab phone (SVH): 613-562-6262 x2245

32. Technology Related Research @ Bruyère Continuing Care Virtual reality in stroke rehabilitation Dr. Hillel Finestone Director of Stroke Rehabilitation Research, Bruyère Continuing CareAssociate Professor, Division of Physical Medicine and Rehabilitation, University of Ottawa

33. Research Team Dr. Hillel Finestone Director, Stroke Rehabilitation Research Elisabeth Bruyère Hospital, Bruyère Continuing Care Associate Professor, University of Ottawa Primary Investigator Dr. Heidi Sveistrup, PhD Professor and Vice-Dean, Research and Graduate Studies Faculty of Health Sciences, University of Ottawa Co-investigator Dr. Martin Bilodeau, PhD Associate Professor and Director, School of Rehabilitation Sciences, University of Ottawa Co-investigator

34. Research Team (cont’d) Anne Taillon-Hobson BSc (PT), MSc Research Associate, VRRASS Dan McEwen PhD candidate, School of Rehabilitation Sciences University of Ottawa Dr. Leo Tseng Division of Physical Medicine and Rehabilitation University of Ottawa

35. Introduction • Balance impairments (Barclay-Goddard et al., 2004) and independent walking (Patel et al., 2000) are frequently impaired in the post-stroke population • Balance has been shown to improve following retraining (EBRSR – Evidence-Based Review of Stroke Rehabilitation, www.ebrsr.com, 2007) • Virtual reality (VR) exercises have been shown to improve balance in the community-dwelling TBI population (Thornton et al., 2005) and in adolescents with cerebral palsy (Brien & Sveistrup, 2011)

36. Introduction (cont’d) • VR exercises transfer to real-world situations (Jaffe et al., 2004; Lam et al., 2006), potentially improving community-based functional activities such as walking in a risk-free environment (Lam et al., 2006) • VR exercises can enhance family/community involvement in rehabilitation of patients (Thornton et al., 2005; Finestone, 2011)

37. Introduction (cont’d) • Laver et al. (Cochrane Database, Sept. 2011)and Deutsch (2012) concluded that future studies investigating the use of VR exercises in rehabilitation should be characterized by: • robust methodologies, including blind and randomized protocols • the inclusion of inpatient populations

38. VRRASS Project Virtual Reality Rehabilitation After Stroke Study • Objectives: • Determine whether VR, as an adjunct treatment, is beneficial for rehabilitation by improving balance and function in the inpatient stroke population • Establish whether VR exercises are safe and feasible to implement in an inpatient rehabilitation environment • Document stroke patient satisfaction with VR exercise programs

39. What is Virtual Reality (VR)? “A simulation of a real world environment that is generated through computer software and is experienced by the user through a human–machine interface” (Holden, 2005)

40. Methods Treatment Group • N = 30 • Conventional therapy + VR exercise while standing Control Group • N = 30 • Conventional therapy + VR exercise while sitting

41. Inclusion Ability to stand independently for >1minute Ischemic or hemorrhagic stroke in left or right cortical or subcortical region Balance and gait deficits resulting from stroke Ability to understand and follow instructions Ability to provide informed consent Exclusion Severe cognitive impairments or unable to follow instructions Unstable medical condition Vestibular deficits or vertigo Seizure activity in past 6 months Inclusion/Exclusion Criteria

42. Outcome Measures • Berg Balance Scale and, if ≥ 48, Community Balance and Mobility Test • Functional Independence Measure (FIM) • Chedoke-McMaster Stroke Assessment (arm, leg, posture) • Two-Minute Walk Test • Timed Up & Go Test • Quasi-static measures (centre of pressure, pressure mat) • Ottawa Sitting Scale

43. Randomization Patient admitted to Élisabeth Bruyère Hospital and assessed for medical suitability Suitable for the Study? YES NO Primary care nurse obtains verbal consent from patient to meet VRRASS research associate Routine care and therapies Patient contacted by VRRASS research associate who details the study to the patient and provides written information Consent form signed and clinical outcome measures initiated YES Patient consents to participate in the study? NO Routine care and therapies

44. Protocol • Daily 30- to 45-minute sessions of which 20–25 minutes are VR exercises • 6–10 sessions • Outcomes assessed three times: • Before training • Following the end of training • 1 month after the end of training

45. Statistical Analysis • Baseline demographics • Repeated-measures analyses to determine significant differences in outcome measures across the three test sessions • SPSS 17.0 software, α level of 0.05

46. Preliminary Results May 1, 2011–April 30, 2012

47. Stroke Unit Patient Demographics N = 206 104 men, 102 womenMean age: 68 years (range 21–89) FIM mean total score: 75 (range 23–114)FIM mean motor score: 55 (range 17–90)FIM mean cognition score: 20 (range 6–33) Eligible for study? Yes 49 No 157

48. Eligible Participant Demographics 49 patients eligible for study Enrolled: 38 20 men – mean age 60 (range 21–86) 18 women – mean age 61 (range 26–88) FIM mean total score 93 (range 62–110) FIM mean motor score 69 (range 37–88) FIM mean cognitive score 24 (range 13–30) Refusals/unsuitable: 11 Hate computers 2 Too anxious to learn 1 Not interested 7 Not stroke 1 Continue with routine care and therapies

49. Participant Demographics 38 patients enrolled 27 active participants 23 have completed 3/3 phases 4 have completed 2/3 phases 10 withdrawals Early discharge 2 Too tired 2 Fear of second stroke 1Increase in cluster headaches 1 Noncompliant with protocol 2 Technical problems 2 1 lost to follow-up

50. Participant Demographic Features