TIP 7 Projects

TIP-7: Telerehabilitation in Artificial Vision Training

Task Leader

Amy C. Nau, D.O., UPMC Eye Center, Eye and Ear Institute

Co-Investigator

Bambang Parmanto, PhD & Michael McCue, PhD

Overview

Blindness is a significant cause of human morbidity that often results in social isolation, increased risk of falling and resultant hip fractures, depression, disability, and premature death.  The past decade has brought technological advances that catapulted the idea of an ocular prosthetics from the realm of science fiction to the brink of reality.

The BrainPort™ (Wicab, Madison WI) pairs a camera to an intraoral electrode display that rests on the tongue. The tactile sensation that is produced can be interpreted by the tongue, much like Braille is read with the fingertips.  The device improves orientation and mobility for patients who are blind or have very low vision by providing information about location, position, size, and shape of objects in the immediate environment. 

The Sensory Substitution Lab at the UPMC Eye Center has worked with the Brainport for two years and has shown that extensive training is required to attain proficiency.  Therapists have established training paradigms for more traditional forms of blind rehabilitation, but most are not even aware that artificial vision is on the near horizon. A major impediment to the adoption of artificial vision by clinicians will be the lack of trained therapy professionals to work with blind patients.

Some artificial vision device prototypes will likely be ready for commercial launch within five years. However, introduction of these devices will fail unless a rehabilitation infrastructure is developed in parallel to support the training with, and use of, the technology. Current blind rehabilitation requires months to years to achieve independence, and the same will be true for artificial vision devices such as the Brainport or the Argus Retinal Implant Chip (Second Sight, Sylmar, CA).  Currently, research teams are developing the rehabilitation protocols for artificial vision devices.
Certified low vision occupational therapists (CLVOT), focus on the use of adaptive equipment to facilitate functional, independent lifestyles in the presence of severe visual disabilities. They will be the primary profession charged with training the blind to use artificial vision devices. However, even with clinical rehabilitation nomograms in place, there will be a shortage of CLVOTs who will be trained in artificial vision, per se. The expected market for artificial vision devices (i.e., persons who are completely blind) is approximately 1 million persons in the United States.  The total number of occupational therapists in the U.S. is approximately 104,000, and only 288 are specifically trained to work in the area of low vision rehabilitation.  This discrepancy poses a serious impediment to the success of artificial vision in general.  Creative methods to overcome this deficiency must therefore be urgently explored.
We feel that telerehabilitation will provide a means for CLVOTs to efficiently treat a greater number of patients without the physical and financial limitations imposed by geographical boundaries.  Like its counterpart, telemedicine, computer and Internet technology will be the cornerstone of this initiative.  Moreover, by allowing therapists in training to virtually observe and work with patients via the Internet, real world internship type activities can be pursued in a cost effective and efficient manner.
We propose collaboration with the Rehabilitation Engineering Research Center on Telerehabilitation (RERC-TR) at the University of Pittsburgh.  This joint effort will capitalize on the existing VISYTER software and hardware needed to establish the physical links between the patient and the therapist. Moreover, their team has developed secure informatics technology based on electronic health record systems. Leveraging already accessible technical and intellectual infrastructure will significantly reduce our team’s ramp up time for this project.

We will use the Brainport Vision Device for this pilot project.  While the work described herein will have broad applicability to the entire field of artificial vision, the Brainport was selected because of it’s proximity to commercial release, the fact that it is non-invasive, and the fact that it’s functionality surpasses any of its competitors at this time.

We plan to accomplish the following objectives within one year:

  1. Determine the software programs needed to successfully integrate the Brainport Vision device with existing tele-rehabilitation architecture.
  2. Determine the barriers to using tele-rehabilitation in a blind population.
  3. Pilot a “companion” training device, which is based on smart phone technology.

Project activities:

To determine best effectiveness for this project, 4 subjects will be enrolled in a pilot program.  All subjects will have light perception vision or worse bilaterally. Inclusion and exclusion criteria will match that of current Brainport studies and are designed to ensure that the objectives of the study are met while offering maximal protection for our participants.  Subjects will be recruited from the existing research registry of blind volunteers at the Sensory Substitution Lab.

Objective 1.  
Determine the software programs needed to successfully integrate the Brainport Vision device with existing telerehabilitation architecture

We will determine which software and hardware platforms will be required for the Brainport device to attain compatibility with already existing telerehabilitation programs that have been developed by the RERCT group.   In addition, we will determine whether any of the telecommunication hardware (i.e., cameras, speakers, internet connections) will need to be modified for blind users.   We will also define the clinical information that will be included for interaction between the subject and CLVOT.

Objective 2.  
Determine the barriers to using telerehabilitation in a blind population.

Because this is a novel application of telerehabilitation, we will need to prospectively design a program that will be “blind friendly”. We will then need to install the hardware into the homes of our subjects and run pilot studies to determine where gaps in our design have occurred as well as obtain user feedback both from the subjects and our research staff who will interact with them on a regular basis.  It is likely that this iterative process will require that we make modifications to our system.

Objective 3.  
Pilot a “companion” training device, which is based on smart phone technology

Our work with the Brainport has shown that having a sighted companion who is willing to assist in their rehabilitation training is beneficial.  While working with our occupational therapy team on site, the blind patients are now coached on what they are detecting by a laptop computer that has a program that demonstrates the signal that is being produced on the tongue.  Wicab has developed a device that is embedded into a smart phone (Droid, Verizon) that can demonstrate the signal that is being produced on the tongue to a sighted companion. This can be carried by the sighted companion to help facilitate interpretation of the blind patient’s surroundings in the home environment.  In this way, the CLVOT can also engage the caregiver in training exercises.  We also plan to determine whether this modified smart phone can be used to log the types of activities the patient is performing with the Brainport. This data could be then be uploaded into the telerehabilitation port for interpretation and evaluation by a CLVOT remotely.


Anticipated Project Outcomes and How They Will Be Measured

Our primary outcome measure will include development of a standard Brainport telerehabilitation videoconference capability with CLVOT.  We have developed and validated a set of standard psychophysical and mobility outcomes assessments for artificial vision that have been successfully applied in ongoing research projects.  We will use these same measures for this project. We will enroll four subjects who will take the Brainport vision device home for a period of 6 months. They will return in six weeks and six months to our facility for performance assessments.  We will compare the results of their outcomes measures to those enrolled in our parallel Veteran’s study, who will not have had the benefit of telerehabilitation.  ANOVA and post-hoc analyses will be used to compare study groups. In addition, we will conduct usability studies that will require administration of standardized usability/satisfaction instruments developed by the RERC-TR to obtain systematic feedback on usability and satisfaction of the TR training technologies from consumers, clinicians and caregivers.


Future Directions

If proof of concept is confirmed, we will use telerehabilitation in our 3-year study funded by the DOD, which is slated to begin in July 2011.  In addition, the results from this project can be used to apply for NIH funding, specifically to explore whether tele-rehabilitation can be expanded to use with retinal implant chip technology.  By working with collaborators at the Retina Foundation (who work with the Argus II retinal implant), we can establish the rehabilitation scaffolding needed to mount a clinically successful launch of artificial vision devices.  Finally, whether telerehabilitation can work with a low vision population should be explored.  Planned collaborations could include investigators at the Lighthouse International, NYC as well as collaborators at Massachusetts Eye and Ear Infirmary and the VA hospitals.

 


Project Update

2011

This new TIP is a collaboration between the Sensory Substitution Lab at the UPMC Eye Center, Brainport and the RERC-TR. This joint effort will capitalize on the existing VISYTER software and hardware needed to establish the physical links between the patient and the therapist. We will use the Brainport Vision Device for this pilot project.
We plan to accomplish the following objectives within one year: 1) Determine the software programs needed to successfully integrate the Brainport Vision device with existing tele-rehabilitation architecture, 2) Determine the barriers to using tele-rehabilitation in a blind population, and 3) Pilot a "companion" training device, which is based on smart phone technology.


 

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