Sex- and gender-based factors disproportionally impact stroke recovery in women, and thus there is an urgent need for rehabilitation scientists to consider innovative forms of delivering stroke rehabilitation to optimize their participation, physical and psychosocial outcomes. Telerehabilitation which involves minimal travel requirements and costs may help overcome barriers related to accessing rehabilitation services. This PhD thesis is comprised of three studies that had an overarching aim of examining the intersection between sex- and gender-based considerations and exercise-based telerehabilitation among individuals with stroke. The first study was a scoping review of 38 primary research studies exploring facilitators and barriers to participation in exercise-based telerehabilitation in men and women with stroke. We reported many facilitators related to environmental factors including variety of games or exercises, convenience/flexibility of the training schedule, accessibility, strong communication skills possessed by therapists, and self-reported improvements in physical function. Challenges with internet connectivity and wearing and/or adjusting the technological device(s) used were the most commonly reported barriers. Both men and women reported being satisfied with the intervention components and possessed knowledge to participate. The second study aimed to explore participants’ experiences with a synchronously-delivered 4-week lower extremity-focused telerehabilitation program. Participants corroborated many of the facilitators identified in our scoping review, in addition to telerehabilitation providing opportunities to extend the continuum of stroke recovery. The third study included multiple case studies of 6 participants involved with the 4-week exercise-based telerehabilitation, whereby we explored sex- and gender-based factors that could potentially explain the responses in performance-based strength and health-related quality of life. We reported that factors such as stroke type and marital status of female participants could have helped explain their more favourable responses in contrast to males. Overall, this thesis provided preliminary evidence of the use of telerehabilitation as a viable means of delivering stroke rehabilitation to women. / Thesis / Doctor of Philosophy (PhD) / Stroke affects men and women differently. Unfortunately, women experience poorer recovery of their limbs and also participate less in stroke rehabilitation services due to factors like being a primary caregiver. Virtual rehabilitation programs may enable more women to benefit from stroke rehabilitation by removing barriers such as the need for travel. The goal of this research was to gather and synthesize information on factors that enabled and impeded participation in exercise-based virtual rehabilitation. We also explored the experiences of people with stroke who participated in a 4-week lower limb focused virtual exercise program, and closely explored their unique physical and psychological responses to the program. Overall, we found many positive factors and few impeding factors to participating in telerehabilitation, and that people with stroke think that virtual rehabilitation is an accessibility form of stroke rehabilitation that improves psychological outcomes and lower limb strength, especially in women.

The problem considered in this thesis is developing a set of digital features relevant in describing finger-hand function of early-onset rheumatoid arthritis (RA) patients. The premise is based on a novel telerehabilitation gaming system that operates on a store-and-forward design. The solution to this problem was to develop a full-scale gaming platform to examine client movement performance for precision aiming tasks based on a set of digital features. To complement the movement performance, still imagery in three unique poses are captured during a session to detect visual symptoms during disease activity and early warning signs of deformities that can arise from joint damage. Resulting data is gathered in a clinic or housed in a content management system where features are extracted and analyzed, providing reports/queries for care providers and allowing remote monitoring. The goal is to help automate monitoring patient finger-hand function between office visits from a remote location, on a smaller scale and with minimal supervision. The contributions presented in this work include development of a detailed set of digital features derived from a custom built gaming platform to highlight client movement performance and algorithms to extract hand structure to approximate goniometry measurements of joint angles monitoring for potential changes during progression of the disease. The significance of this contribution is that it provides a readily accessible, experimental platform for the provision of physical therapy tailored to the individual RA patient through the use of a telerehabilitation gaming platform.

Este trabalho apresenta o desenvolvimento de um ambiente de estudos para Telereabilitação Robótica utilizando jogos cooperativos desenvolvidos com o ambiente de desenvolvimento Unity e comunicação via sockets baseados em TCP/IP. Para tanto, fez-se necessário a implementação de um programa de controle de comunicação, um jogo e um sistema robótico. A fim de estudar este ambiente, foram implementados três métodos de comunicação entre o sistema robótico e o jogo, de acordo com a literatura. Os métodos são: Controle Teleoperado Direto (PD Simétrico), Controle Teleoperado por Variáveis de Ondas e Controle Teleoperado através de Ambiente Virtual. Para realizar a avaliação destes métodos foram implementados quatro simulações de atraso de comunicação, onde os seguintes parâmetros foram avaliados: estabilidade das mensagens enviadas e recebidas, sincronismos dos motores do sistema robótico e seus parâmetros (torque e velocidade) e sincronismo do sistema robótico com o ambiente lúdico (jogo). As situações de atraso criadas foram de: 1 milissegundo, 300 milissegundos, 600 milissegundos e 900 milissegundos. Todos os métodos implementados se mostraram suscetíveis a altos índices de atraso (especialmente ao testarmos atrasos artificiais de 600 e 900 milissegundos). O método que apresentou menores falhas foi o de controle de variáveis de ondas. / This dissertation presents the development of an study environment for telerehabilitation robotics using cooperative games developed with Unity (Game Engine) and communication with sockets based on TCP/IP protocol. For this purpose, it was necessary to implement a control program of communication, one game and a robotic system. To study this environment, three methods of communication between the robotic system and the game according to the literature were implemented. These methods are: Direct Teleoperated Control (symmetrical PD), Teleoperated Control for Wave Variables and Teleoperated Control through Virtual Environment. In order to evaluate these methods were implemented four simulations delay of communication, where the following parameters were evaluated: stability of messages sent and received, timings of the motors of the robotic system and its parameters (torque and speed) and timing of the robotic system with playful environment (game). The delay simulations were created: 1 millisecond, 300 milliseconds, 600 milliseconds and 900 milliseconds. All implemented methods proved susceptible to high rates of delay (especially when we test artificial delays of 600 and 900 milliseconds). The method presented minor flaws was the Teleoperated Control for Wave Variables.

Este trabalho apresenta o desenvolvimento de um ambiente de estudos para Telereabilitação Robótica utilizando jogos cooperativos desenvolvidos com o ambiente de desenvolvimento Unity e comunicação via sockets baseados em TCP/IP. Para tanto, fez-se necessário a implementação de um programa de controle de comunicação, um jogo e um sistema robótico. A fim de estudar este ambiente, foram implementados três métodos de comunicação entre o sistema robótico e o jogo, de acordo com a literatura. Os métodos são: Controle Teleoperado Direto (PD Simétrico), Controle Teleoperado por Variáveis de Ondas e Controle Teleoperado através de Ambiente Virtual. Para realizar a avaliação destes métodos foram implementados quatro simulações de atraso de comunicação, onde os seguintes parâmetros foram avaliados: estabilidade das mensagens enviadas e recebidas, sincronismos dos motores do sistema robótico e seus parâmetros (torque e velocidade) e sincronismo do sistema robótico com o ambiente lúdico (jogo). As situações de atraso criadas foram de: 1 milissegundo, 300 milissegundos, 600 milissegundos e 900 milissegundos. Todos os métodos implementados se mostraram suscetíveis a altos índices de atraso (especialmente ao testarmos atrasos artificiais de 600 e 900 milissegundos). O método que apresentou menores falhas foi o de controle de variáveis de ondas. / This dissertation presents the development of an study environment for telerehabilitation robotics using cooperative games developed with Unity (Game Engine) and communication with sockets based on TCP/IP protocol. For this purpose, it was necessary to implement a control program of communication, one game and a robotic system. To study this environment, three methods of communication between the robotic system and the game according to the literature were implemented. These methods are: Direct Teleoperated Control (symmetrical PD), Teleoperated Control for Wave Variables and Teleoperated Control through Virtual Environment. In order to evaluate these methods were implemented four simulations delay of communication, where the following parameters were evaluated: stability of messages sent and received, timings of the motors of the robotic system and its parameters (torque and speed) and timing of the robotic system with playful environment (game). The delay simulations were created: 1 millisecond, 300 milliseconds, 600 milliseconds and 900 milliseconds. All implemented methods proved susceptible to high rates of delay (especially when we test artificial delays of 600 and 900 milliseconds). The method presented minor flaws was the Teleoperated Control for Wave Variables.

When vestibular sense organs suffer damage functional problems arise such as imbalance and falls as well as difficulty with gaze control, resulting in blurred vision, dizziness and feelings of disorientation. A novel computer-based rehabilitation program has been developed. Using the Gyration TM motion-sense mouse, attached to a headband, to control computer applications and games, the participants were able to interact with targets in computer games through head motion, allowing different gaze exercises to be carried out. Balance exercises can be incorporated simultaneously and progressively into the rehabilitation program. The main findings of this study revealed that using head rotation to interact with computer games coupled with demanding balance conditions resulted in substantial improvements in gaze control, standing balance and walking performance. These observations provide support that a low-cost home computer-gaming rehabilitation program is well suited to train gaze control through active and passive head motion and to concomitantly train standing balance.

When vestibular sense organs suffer damage functional problems arise such as imbalance and falls as well as difficulty with gaze control, resulting in blurred vision, dizziness and feelings of disorientation. A novel computer-based rehabilitation program has been developed. Using the Gyration TM motion-sense mouse, attached to a headband, to control computer applications and games, the participants were able to interact with targets in computer games through head motion, allowing different gaze exercises to be carried out. Balance exercises can be incorporated simultaneously and progressively into the rehabilitation program. The main findings of this study revealed that using head rotation to interact with computer games coupled with demanding balance conditions resulted in substantial improvements in gaze control, standing balance and walking performance. These observations provide support that a low-cost home computer-gaming rehabilitation program is well suited to train gaze control through active and passive head motion and to concomitantly train standing balance.

O acidente vascular cerebral (AVC) é a principal causa de mortes no Brasil entre os óbitos por doenças cerebrovasculares e a principal causa de incapacidade no mundo. Este é um problema substancial de saúde pública e econômico, representa mais da metade dos pacientes neurológicos hospitalizados e muitos apresentam sequelas como hemiparesia, dependência completa ou parcial, afasias e dificuldade na deambulação. Um recurso para potencializar a reabilitação é a \"Telereabilitação\" (TR), que usa as tecnologias de informação e comunicação (TIC\'s) para acompanhamento à distância. Inúmeros benefícios da telessaúde e TR já foram descritos, incluindo um melhor acesso aos serviços de saúde, custo-eficácia, mais oportunidades educacionais, melhoria dos resultados na recuperação, melhor qualidade dos cuidados, melhor qualidade de vida e reforço dos suportes sociais. O presente trabalho realizou um levantamento da percepção dos profissionais e das ferramentas utilizadas por terapeutas ocupacionais para acompanhamento à distância de pacientes com seqüelas de AVC, assim como introduziu ferramentas de TR (mensagens de texto, telefonemas, chats online, etc) em serviços de reabilitação da cidade de Ribeirão Preto e verificou sua viabilidade de uso com estes pacientes. O estudo se desenvolveu em duas partes: 1) levantamento da percepção dos profissionais e das tecnologias usadas nos serviços de terapia ocupacional através de um questionário semi-estruturado; 2) implantação de ferramentas de acompanhamento à distância integradas ao acompanhamento convencional. A parte de implantação foi dividida em duas fases. Na primeira com o uso de somente uma ferramenta para acompanhamento do paciente (por exemplo a mensagem de texto via celular) e a segunda com o uso de duas ferramentas em conjunto (telefonemas e mensagens de texto). O acompanhamento dos pacientes em cada fase foi pelo período de no máximo dois meses. A viabilidade de uso das tecnologias foi avaliada nos aspectos de tempo dispensado para uso, facilidade, percepção de utilidade e adesão à ferramenta, que foram analisados através de questionários estruturados aplicados com o terapeuta do serviço e o paciente. Obteve-se como resultado da primeira parte do estudo um levantamento com 27 terapeutas ocupacionais. Na segunda parte as ferramentas foram introduzi das no tratamento de 9 pacientes. Foi verificado que muitos profissionais já utilizam na clínica as tecnologias de informação e comunicação para acompanhamento à distância. Pôde-se discutir sobre a importância da ética no uso de tecnologias para acompanhamento à distância, da consideração de aspectos como da confiabilidade da informação fornecida pela tecnologia, avaliação das habilidades do paciente para uso, uso de tecnologias de uso prévio do paciente, avaliação da sua rotina e hábitos de vida no momento da escolha da ferramenta. Os pacientes acompanhados não apresentaram dificuldades no uso das ferramentas introduzidas, relataram satisfação com uso e foi observado pelos terapeutas a facilitação do processo de reabilitação através da maior adesão das orientações, monitoramento do paciente e motivação na terapia. / Stroke is the leading cause of death in Brazil between deaths due to cerebrovascular disease and the leading cause of disability worldwide. This is an issue of substantial public health and economic accounts for more than half of patients hospitalized and many have neurological sequelae such as hemiparesis, partial or complete dependence, aphasia and difficulty in walking. A resource for enhancing rehabilitation is \"Telereabilitação\" (TR), which uses communication technologies for distance care. Numerous benefits of telehealth and TR have been described, including improving access to health services, cost-effective, more educational opportunities, improved results in recovery, better quality of care, better quality of life and strengthening social supports. This study conducted a survey of the perceptions of professionals and the tools used by occupational therapists for remote monitoring of patients with sequelae of stroke, as well as introduced the TR (text messages, phone calls, online chats, etc.) tools in rehabilitation services the city of Ribeirão Preto and verifted its feasibility of use with these patients. The study was conducted in two parts: 1) raising the awareness of professionals and technology used in occupational therapy services through a semi-structured questionnaire; 2) implementation of the integrated monitoring to conventional monitoring tools away. The deployment part was divided into two phases. At first only with the use of a tool for monitoring the patient (e.g. via mobile text message), and the second using two tools together (phone calls and text messages). Monitoring of patients in each phase was the period of maximum two months. The feasibility of using technology was evaluated in the aspects of time allocated for use, ease, perceived usefulness and adherence to the tool, which were analyzed using structured questionnaires with the therapist and the patient service. Obtained as a result of the first part of the study a survey of 27 occupational therapists. In the second part the tools were made in the treatment of patients 9. It was found that many professionals now use in clinical information technology and communication for remote monitoring. We can discuss about the importance of ethics in the use of technology for remete monitoring, the consideration of aspects such as the reliability of the information provided by the technology, skills assessment of the patient to use, use of prior patient use technologies, assessment of your routine and lifestyle in their choice of tool. The patients monitored had no difficulties in using the tools introduced, reported satisfaction with use and was observed by the therapists facilitating the rehabilitation process through greater adherence to the guidelines, patient monitoring and motivation in therapy.

Background: A computer game based Telerehabilitation platform has been developed to provide a seamless system for hand exercise and assessment in home settings for people with arthritis. The exercise program involves task-oriented training of real life object manipulation tasks performed with computer gaming. The platform will also be integrated with a telemonitoring, computer game based hand function assessment application. Objectives: 1) To determine test-retest reliability and convergent validity of the assessment application protocol in people with rheumatoid arthritis or hand osteoarthritis, 2) To conduct a pilot randomized controlled trial for assessing the feasibility, and therapeutic effects of the task-oriented training compared to conventional hand exercises, and 3) To qualitatively evaluate participants’ experiences on their respective exercise programs. Methods: Performance during three different object manipulation tasks was evaluated by the assessment application protocol on 40 people with arthritis. The performance measures were correlated with other common hand function measures. A six-week pilot randomized trial was conducted on 16 individuals with arthritis. The Arthritis Hand Function Test (AHFT), the Disabilities of Arm, Shoulder and Hand (DASH) questionnaire, exercise compliance and task performance during three object manipulation tasks were the clinical outcomes. Focus group interviews were conducted on seven participants who had before received their home exercise programs. Results: The protocol demonstrated moderate to high test-retest reliability (ICCs between 0.5-0.84) of performance measures. Spearman correlation coefficients (rho) between task performance measures and other measures of hand function were low to moderate (0.4 < rho < 0.5 to 0.7). The pilot trial was not successful in terms of participant recruitment but demonstrated feasibility of study procedures, resources, and management. Except for two dexterity sub-scales of the AHFT, there were no significant differences in other clinical measures. Exercise compliance was >85% in both groups. The qualitative study provided initial evidence on the appropriateness, acceptance, perceived benefits, and a few practical difficulties in performing each exercise program. Conclusions: The hand function assessment application warrants validation in a variety of object manipulation tasks and in different patient populations. In order to proceed to a full-fledged trial, additional recruitment strategies, and revisions in the inclusion criteria must be considered. / February 2015

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