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Engaging Game-based Home Rehabilitation for Improved Quality of Life

Final Report Summary - REHAB@HOME (Engaging Game-based Home Rehabilitation for Improved Quality of Life)

Executive Summary:
The project was focussing on solutions for patients after a stroke to supply them with a sustainable progress in rehabilitation. The research refers to the upper part of the body, especially the movement of the arms, the grip and the wrists. As medical and technical partners are involved in this project as well as patients, an ongoing rehabilitation process can be evaluated in depth. The project’s aim was to design and develop an open- solution IT-device (concept, hardware/software) that allows the patient to exercise at home to reduce his disabilities. The device offers features and functionalities as a set of exercises based on personalised serious games adapted to the patient’s needs. The challenge on the one side was to develop games which are motivating for the patient and allow him to improve at the same time. The plan is to have the first training with the device during the patient’s stay at the hospital, enabling him to continue his training at home. The games used for a patient are selected individually by the physician and are calibrated to the patient’s needs and abilities, ensuring and optimum degree of exercise.. The player collects rewards as a real-time feedback during his training. As a socialisation component, the patient can also compete with friends or family members.
During the training with this user-friendly IT-device, information about the quality of the performance is provided to the medical personnel. The physical and medical parameters are monitored and evaluated by an on-line/off-line management at the medical centre. The rehabilitation protocol provides a good overview of the patient’s progress to the medical personnel and allows the challenges of the games to be adjusted to the patient’s condition.
The device consists of commercial products like Microsoft KinectTM and using Web2.0 social networks. In this way an effective, efficient and attractive virtual environment for a successful rehabilitation can be built at the patient’s home. Because of the individual handicaps of the game’s users, the challenge was to optimise the games in such way that the training is sufficient for the patient and has enough stimulation to keep the patient exercising. The components themselves are low-cost, robust, good to handle and easy to use. Also, the therapeutic data, physical as well as physiological, are collected via the sensors, and are evaluated with the software developed during the project In this way the medical care can be online as well as off-line. The result of this new kind of service model proposed by Rehab@Home targeting the new technology, coupled with training, demonstration and dissemination will be the integration in the existing public healthcare service.

Project Context and Objectives:
In 1997 the number of over-65 year olds constituted 6.6%of the world’s population, and this is predicted to increase to 10% by 2025. It is expected that this will lead to a rise in demand for long-term residential care. Common elderly diseases and ailmentsinclude one or more of the following: arthritis, cancer, cardiovascular (e.g. blood pressure and heart disease), cerebrovascular (e.g. strokes), dementia, depression, diabetes, falls and injuries, gastrointestinal disorders, hearing impairment, memory, osteoporosis, Parkinson's and Alzheimer’s diseases, respiratory disease, pressure ulcers, sleep problems, thyroid disease, urinary disorders and visual impairment. In many cases, considerable health gain, both from the physical and cognitive perspectives, can be achieved by successful rehabilitation, which is concerned with lessening the impact of specific disabling conditions.
Considering that the aforementioned set of diseases is very broad, to the Rehab@Home project focussed more on one specific indication, stroke. Stroke is the 2nd most common cause of death in Europe (1.24 million annual) and in the European Union (508,000 annual) and the 3rd cause of death in Canada (14,000 annual) and the United States (over 143,000 people each year). Meanwhile, 1.8% of Asians aged 18 years and older have had a stroke. In general, according to the World Health Organization, about 15 million people suffer from stroke worldwide each year. Of these, 5 million die, 10 million survive, though showing different degrees of disabilities. Accordingly, the costs of stroke are enormous. In Europe and the USA, 2-6% of all health care costs are spent on direct stroke care, including the costs of hospital and nursing home care, the services of physicians and other medical professionals, drugs, appliances, and rehabilitation. (Evers S, et. al., "International Comparison of Stroke Cost Studies," Stroke 35:1209-15, 2004.) Indirect costs, defined as production losses, further increase the burden of the disease. In Europe, direct costs are in the range of 3.000-16.000 Euros per patient during the first year, whereas the lifetime direct cost may reach 30.000 Euros. Taken together, direct and indirect costs may be as high as 20.000-26.000 Euros per patient in the first year. In Europe, 22 billion Euros are spent on stroke annually (Truelsen T, et al., "Cost of stroke in Europe," Eur. J. Neuro. 12, Suppl 1:78-84, 2005).
Stroke affects everybody differently, and it is difficult to say how much of a recovery is possible. Many stroke survivors experience the most dramatic recovery during their stay in hospital in the weeks after their stroke. But many stroke survivors continue to improve over a longer time, sometimes over a number of years. The goal of rehabilitation is to help survivors become as independent as possible and to attain the best possible quality of life. Rehabilitation does not "cure" stroke in that it does not reverse brain damage. High quality rehabilitation however is essential to regain many – if not all – of their capabilities.
The first stage of rehabilitation usually occurs within an acute-care hospital, as soon as the patient is stable and the (initially high) risk of recurrence is lower. 10% of the survivors can return home quickly, many need to be treated in some type of medical facility. For over half of the of stroke survivors, rehabilitation will be a long-term process requiring work with therapists and specialized equipment for months or (ideally) years after the stroke.
However, increasing cost pressure on the health system will lead to shorter periods of intensive rehabilitation at specialized facilities. Within this context the adoption of suitable technical aids at home, together with a proper training program, can help reducing the patient’s stay at the hospital as well as the need for moving him/her between home and a physiotherapy unit or a paramedical structure.
Rehabilitation, which may be effective in improving the physical and mental condition of older people in long-term care, is a complex set of procedures usually involving several professional disciplines and aimed at improving the quality of life of older people facing daily living difficulties caused by either temporary and/or chronic diseases. Comprehensive rehabilitation needs to address a number of different levels which may be contributing to loss of function: the damaged body part and other related body elements, psychological attitudes, immediate material environment (e.g. clothing items), the surrounding indoor environment (e.g. housing/equipment), external environment (e.g. shops, social outlets), social support networks.
In the specific case of stroke, rehabilitation is based on Neuroplasticity (also known as cortical re-mapping), which is the brain's ability to reorganize itself by forming new connections, allowing nerve cells in the brain to compensate for defects. However, neuroplasticity is only happening when there is ‘right’ stimulus and sustainable motivation, which are the key factors of successful rehabilitation. Rehabilitation teaches new ways of performing tasks to circumvent or compensate for any residual disabilities. There is a strong consensus among rehabilitation experts that the most important element in any rehabilitation program is carefully directed, well-focused, repetitive practice - the same kind of practice used by all people when they learn any new skill, such as playing guitar or skating.

Rehabilitative therapy begins in the acute-care hospital after the patient's medical condition has been stabilized. The first steps involve promoting independent movement because many patients are paralyzed or seriously weakened. Patients are prompted to engage in passive (the therapist actively helps the patient move a limb repeatedly) or active (exercises are performed by the patient with no physical assistance) range-of-motion exercises to strengthen their stroke-impaired limbs. Rehabilitation nurses and therapists help patients perform progressively more complex and demanding tasks and encourage patients to begin using their stroke-impaired limbs while engaging in those tasks. Beginning to reacquire the ability to carry out these basic activities of daily living represents the first stage in a stroke survivor's return to functional independence.
Up until recently it was assumed that an early rehabilitation immediately after the stroke event is the key to achieve a good functionality recovery for hands, arms or legs. No major improvements were expected from a delayed rehabilitation process. Recently, it has been demonstrated that relevant results can be obtained many years after the stroke as well, provided that a specific and very intensive rehabilitation approach is applied (A.C. Wallace et al., “Standardizing the intensity of upper limb treatment in rehabilitation medicine”, Clin Rehabil May 2010 24: 471-478). This opens new horizons for stroke patients and further puts the accent on the need for innovation in rehabilitation, both in terms of methodologies and technologies.
Starting from this perspective the Rehab@Home project focused on those medium- long-term rehabilitation steps and activities that could take place at the patient’s home instead of at a dedicated treatment unit. The main objective of Rehab@Home is to transform the patient’s home in a place where the physical and cognitive rehabilitation processes can be performed in an intensive and controlled fashion. In practice, after a short rehabilitative period in a specialized centre the patients can go home where, with a set of easy-to-use technical implements that enable them to exercise in a motivating personalized program. The patient will not only be in contact with experts in the rehabilitation centre - providing guidance and feedback - but will also enjoy the participation in a sort of “virtual gym”, a community-like rehabilitation environment connecting fellow convalescents to increase inclusion and motivation.
The very basic idea behind Rehab@Home was inspired by existing commercial products like Nintendo Wii, Sony PlayStation Move and Microsoft KINECT: such game platforms allow the user to act and interact with other users within a virtual environment, thanks to special interaction devices and suitable technologies to monitor the real environment and track the user(s) behaviour in it. These are proprietary solutions characterized by limited extensibility and flexibility. Moreover, they are intended as gaming platforms, without any specific feature conceived and designed for a straightforward adoption in the medical practice. Having this in mind, the project aimed at the design and development of an open solution (concept, hardware/software, service) able to offer the following features and functionalities:
-proposing a set of exercises within a personalized, serious-games based, rehabilitation program, properly designed according to the patient’s specific needs and able to dynamically and automatically adapt to the user’s behaviour/reactions. Ad hoc, real time, configuration of the proposed physical and visual stimulations mediated by the virtual environment where the patient is acting
-training of both the patient and his/her family members to the execution of the exercises by means of lightweight and user friendly - though highly “informative” for medical experts – devices. Off-line/on-line management of the rehabilitation protocol by the medical personnel/physiotherapist
-acquisition and recording of relevant physical and physiological parameters, by means of suitable sensors. Proper software applications were developed within the project for analysing the collected data, with the aim of providing a qualitative and quantitative picture of the patient’s status and progress
-promotion of social inclusion and community building by means of suitable Web 2.0 tools, to prevent depression and stimulate patient’s reintegration within daily life.

The Rehab@Home project followed a robust and consolidated research and development approach, in order to achieve the following outcomes:

-in-depth knowledge of the rehabilitation operational context: observation of the actual rehabilitation process, analysis of existing medical protocols, definition of a set of representative use and test scenarios, adoption of a robust requirements engineering procedure. This part of the research was aimed also at identifying the target users (specific disease and disabilities) that might benefit at best from the project technical achievements
-specification and design of an in-home multipurpose rehabilitation platform: technical specifications and design of the Rehab@Home solution, including
-a flexible and reconfigurable, modular, hardware platform. Conceptually, this is a set of stand-alone components (sensors, actuators, textile items, communication modules, interaction, visualization and storage devices, etc.) that can be easily selected, aggregated and integrated according to the needs of each specific application scenario
-an open service-oriented architecture, where each service represents a standalone, coherent and self-consistent sub-set of the functionalities to be provided by the solution (e.g. interaction management, visualization, information extraction, data logging, remote collaboration, e-learning/e-training, serious games and community engine, etc.)
-demonstrator of the rehabilitation platform: subsets of functionalities characterized by different levels of priority were identified. Features of the system were implemented incrementally according to increasing priorities.
-assessment of the rehabilitation platform: each prototype was assessed through the involvement of real users, both patients and professionals, taking into account the Living Labs approach. Testing in the different development phases was based on both a suitable assessment protocol and the definition of test cases and use scenarios already in the requirements engineering process. During the testing phase the need for efficient training of both patients and family members was addressed
-definition of an exploitation, development and commercialization plan: this objective aimed at identifying the actual potentialities of the project outcomes in real life. Very important as part of this activity, in order to promote the actual adoption of the solution was the definition of a “service model”, i.e. the most suitable way to integrate the new rehabilitation service within the portfolio of existing public healthcare services.
-scientific validation of the patient’s health improvements: this objective aimed to determine improvements compared to alternative rehabilitation concepts by existing methods taken from occupational therapy, physiotherapy and neurophysiology. A large set of tests to compare rehabilitation concepts is known. Meaningful test are dependent on the patient group.

Project Results:
Summary and system overview
The Rehab@Home project did an extensive investigation of the issues related to long-term physical/cognitive rehabilitation processes and the identification of suitable technical solutions. We wanted to enable elderly people to enjoy high quality rehabilitation for a much longer period than the Health System can currently afford.
By investigating and using standard hardware components and devices, suitable medical data processing algorithms, personalized and serious-games based rehabilitation pathways, Web2.0 social and communication tools, the project developed an efficient, effective and engaging virtual rehabilitation environment for home-based rehabilitation.
Existing commercial platforms inspired the basic project idea. Products like Wii, Kinect and Leap Motion allow the user acting within a virtual environment and interacting with other users.
Figure 1: high level architecture of the overall system (see attachement
As an outcome, Rehab@Home provides a system (Figure 1) that provides exercises and training - based on serious-games - within a personalized, user friendly and engaging rehabilitation program. It offers a cost effective and light infrastructure with integrated sensors. Relevant physical and medical parameters for patients’ status inspection and relapse prevention support off-line/on-line management and monitoring of the rehabilitation.
Rehab@Home can thus transform the patient’s home in a place supporting physical and cognitive rehabilitation processes in an intensive and engaging though properly controlled way, while promoting social inclusion and quality of life.
According to Figure 1 the following four components forming the system were developed:
1. Patient client - The patient client is for patients where therapists deploy advised games patients need to play while wearing physiological devices.
2. Therapist client - The therapist client allows therapists or medical experts to configure individually for the patient’s therapy a set of games and activities for later monitoring performed activities and related health conditions.
3. Family client – The family client allows patient’s family members or care givers to give feed-back based on relevant but compared to the therapist client limited information
4. Back-end system – The back-end system stores the patient history including physiological data, activities, game scores etc.
Computer experts developed the system. However, the users are doctors, patients, caregivers and patients’ relatives. Therefore, all users and stakeholders will need training.

The main technical results in detail
Patient client
Overview on patient client
The patient client is a core component. The patient client is divided in “games” and input/physiological devices. Besides the game environment, the solution also allows the remote management of the patient’s data during their Rehab@Home program. It assists the professional user in the different phases of the therapy: e.g. therapy set up (plan-of-care creation, selection and assignment of therapy games), access to patient data collected during the therapy, personalization of the therapy, and communication with patients.
Patient client details
Patient Client - Control Centre
The operational role of the Patient Client is guaranteed by the Control Centre (CC). The CC coordinates all the other components and it is the core of a centralized structure.
The CC has been designated as the component whose task is receiving all the messages from other components and routing them to the right destination.
Moreover the CC must be always on when the Patient Client is active, because it has to launch and terminate the software processes of other components, for instance to start the right game to be played at a certain time.
Furthermore the CC is fully configurable, new games and alternative components can be added to the patient client in a configuration file.
The configuration also allows new routes for messages to be defined and thus provides an easy way to extend the patient client for new functionality.

This allows us to choose between three different SAC implementations that serve different purposes. The first one exists only for testing and provides a user interface to configure the received health data; it does not connect to a real sensor.
The second one provides health data from the eHealth-platform. The third one is primarily used in the patient client, which connects to a wireless sensor.
Finally, the CC needs to provide a temporary storage and to memorize data that are passed between components. In fact each component of the Patient Client has been designed to not provide internal memory: when a process is killed, every data is lost. For example, when a new session is started, a unique identifier is generated within one of the Patient Client component, but the others need to receive it too.

Patient Client - Menu Component
The Menu Component (MC) is provided with a graphic user interface. This consists of the first view shown to the patient when he/she starts the Patient Client machine.
The patient can read and reply to messages from the therapist or other patients in case that the social integration is enabled for him/her.
Meanwhile the MC retrieves the list of games which the patient has to play during the day.
When the patient is ready to start his/her training, the MC will display the list of games available, but only one at a time is enabled and playable: the user must follow the schedule dictated by the therapist.
Figure 2: List of Games (see attachement)
Patient Client - Signal Acquisition Component
The Signal Acquisition Component (SAC) is a modular platform that allows adding several biomedical sensors to be attached to patient body. SAC carries out the raw acquisition and it doesn't elaborate the data that are transmitted to Signal Interpretation Component for this purpose. A very advanced and complete platform to perform biometric and medical application is e-Health Sensor Shield that allows acquiring pulse, oxygen in blood, breathing airflow, electrocardiogram, galvanic skin response, blood pressure among other things.

Patient Client - Signal Interpretation Component
The Signal Interpretation Component (SIC) is a processing software with the aim of monitoring the level of interest, effectiveness and difficulty perceived by the patient during the game.
The SIC receives a critical threshold (for example the upper limit for heart rate) set by therapist in the medical chart and it continuously checks if the patient is about to cross that limit comparing it with the data stream from SAC. The built in algorithm establishes if the user should stop the game.
All biomedical data sent by SAC to SIC are logged.

Patient Client - General Data Interface
The General Data Interface (GDI) is the gateway with the external world. This software is allowed to access to Central Information Storage (CIS) data storage and read/write data on it.
GDIC retrieves information useful for the game session execution like the heartbeat threshold values for the patient or the list of games to be played in the daily session.
In the end GDIC will receive the logs generated by both the GC and SIC and it will store this information in the CIS data storage.
Figure 3: Patient client structure (see attachement)

Game based rehabilitation environment
Overview on the game-based rehabilitation environment
The main objective of Rehab@Home is to transform the patient’s home into a place where physical and cognitive rehabilitation programs can be performed in a safe and controlled way.
The solution proposed relies on a set of easy-to-use equipment and game environments that the patient can use independently at home, with the participation of caregivers and/or family members to facilitate patient’s inclusion and motivation, while an expert therapist or doctor can monitor the progress of rehabilitation activities remotely.

Game based rehabilitation environment features and functionalities
The Rehab@Home Game Based rehabilitation environment makes use of the Microsoft Kinect technology linked to a desktop computer. The Kinect is able to detect and recognise the movement of a single hand for patients with limited mobility and the environment can be calibrated to adjust the difficulty of the games to the capabilities of the individual.
Initial Calibration
Screen 1 (see attachement)
Screen 2 (see attachement)
The player begins by moving their hand to control the cyan dot on screen 1 to try to reach or get as close as possible to the red square within 10 seconds. This is repeated for each of the corners of the display to calibrate the patient’s mobility. This information is then used to display the 4 red squares on Screen 2 which represent the limits of the patient mobility and the patient then moves the cyan dot to each of the corner squares in turn to verify their mobility capability. If the patient cannot touch one of more of the squares, the Kinect can be reset to repeat the calibration process from Screen 1 until the patient can reach all four corners of the display.
The Games
Menu Screen 1 (see attachement)
Menu Screen 2 (see attachement)
All of the games can be accessed by patient hand movement to select individual games and/or calibration. The games have been designed to be fun, motivating whilst stimulating both physical and cognitive development. They have been co-designed with both patients and medical professionals so that they can not only be played safely at home but also provide important data to the clinicians on the capabilities of the patient. Clinicians can thereby adjust the complexity or difficulty of the game to suit the patient development.

Biosensor to Measure Pulse (see attachement)
Kinect Environment (see attachement)
Rest Game Video (see attachement)
Flowers and Bees Game (see attachement)
Popping Flowers Game (see attachement)
Coloured Cans Game(see attachement)
Grab your can Game (see attachement)
Blackboard Game (see attachement)
Mad Fridge Game (see attachement)

The above screenshots illustrate the games and the use of biosensors to measure the heart rate of the patient along with “rest game videos” which are played before and between games to relax the patient and collect some baseline data for clinical analysis.
Each of the games shown above can be controlled by a single hand movement and the difficulty of the games can be adjusted by the clinician to encourage continuous improvement in physical and cognitive development. Various parameters that can be adjusted by the clinician to make the games more challenging include the speed at which objects travel down the screen, the number and density of objects and the number of colours used in the game.
Whilst the primary aims of the games are to support physical rehabilitation, it is important to mention that they are also intended to encourage cognitive rehabilitation.

Therapy client
Overview on the therapy client
This is a therapy management tool. It allows the continuous monitoring, management and communication with patients during their rehabilitation activities. It can be used by the clinical staff to personalize and schedule the program exercises for each patient and for tuning the rehabilitation program on the fly.
Long-term, statistical analysis of collected data and information, by taking into account the data produced by the 'Patient Client' during the patient’s interaction with the games, such as motion data, games data and usage information. The analysis of the collected data supports therapists and clinicians in understanding the level of progress during the rehabilitation process and in choosing possible adjustments, both in the short and long term; thus it provides a solid background for a more effective planning of the rehabilitation plan.

Therapy client details
The presentation of information and the access to functionalities of the Therapist client interface has been designed by taking into account that the most significant information and functionalities should be readily available. Indeed, it is proved that when analyzing a web-page, users search for some fixed points or anchors which guide them through the content of the page.
In order to make the navigation of the web interfaces as intuitive as possible, we focused on lowering the cognitive load required to access the functionalities and information required so as to make them easy to grasp or inspect. Where possible, information support is provided to enable professional users to take their own decisions consciously, by considering pros, cons and alternatives.
The main functionalities/services integrated into the Therapist client can be found in the following figure:
Figure 4: Main menu of the Therapist Client Interface (see attachement)
User Management Service:
This module includes all functionalities for managing users. Only the administrator and the authorized personnel (i.e. therapists) are allowed to access these resources and functionalities related to user management. The Therapist interface provides the following functionalities related to managing user accounts:
• Creation of a new patient account – Therapists are allowed to create new patients accounts.
• View/modify patient personal profile – The interface provides the option to view and update patient's profile.
• Patient Search – This function allows the users to search for a specific patient.
• Insertion of additional notes - The interface provides the therapists the option to store additional notes about the patient, which can be helpful in the ongoing therapy.
• Creation of a new therapist account – Only the administrator can create the therapists account.
• Creation of a caregiver account – Only the administrator can create a caregiver account.
Rehabilitation Monitoring and Configuration Service:
This module consists of the management of patient rehabilitation activities. This is the central part of the application and the most sensitive one. It includes the components related to the assignment and configuration of rehabilitation exercises.
The main functionalities of this section are defined below:
• Visualization of the Plan-of-care - This section provides the therapists the opportunity to visit the summarization of a patient's past and ongoing therapy.
• Assignment and configuration of a new exercise - Assignment and configuration of a new exercise is a process with multiple steps.
º Step 1 – Specification of the movements
º Step 2 – Choice of the games
º Step 3 – Configuration of the game parameters
º Step 4 – Configuration of the duration and repetition
Data Visualization Service:
The data visualization module provides access also to statistical data related to the therapy. Even if tracking and quantification technologies allow to easily capture and share significant health-related information (on a daily basis), they can generate a large amount of data. The ways in which people analyze and engage with visualized personal data are as significant as the data itself. For this reason we decided to adopt a multilevel approach to data.
This module consists of the functionalities related to visualization of statistical data that are produced by the 'Patient station' during patient’s interaction with the games. The processing and graphical visualization of the statistical data has been designed with the goal to retrieve the most significant information that can help the therapists to evaluate the performance of the patients during the rehabilitation process. This visualization process will help in quick identification of anomalies or significant information.
The functionalities of this data visualization module are described below:
• Visualization and evaluation of performance – This functionality provides the opportunity for the therapists to evaluate the performance of the patient by observing the results of a single session and also by comparing the performance over multiple sessions.
º Performances of a single session - The following results are collected from a single game session.
▪ Calibration data that is measured during the start of the rehabilitation session.
▪ Total score collected during the game session.
▪ Percentage of collected items. 'Positive-Percentage' indicates the percentage of correct items collected and 'Avoid-Percentage' indicates the percentage of wrong item avoided by a patient during the game session.
▪ Collected score in different quadrants.
▪ Collected score in time intervals – This graph shows the collected score of a patient for each 5 seconds interval during the game session.
▪ Bio-graphs – This consists of the graphs that are processed from the data provided by the wearable sensors of the patient during the game session. For example, histograms of the heart-rate of the patients during the game sessions.
º Performance comparison over multiple sessions – This functionality allows the therapists to evaluate the performance over multiple sessions for a long term duration (i.e. 15 days, 1 months, etc.).
• Comparison of scores over multiple sessions
• Comparison of scores and difficulty levels (i.e. easy, medium, tough) over multiple sessions.
• Comparison of collected scores in time intervals for the last 3 sessions.
• Rehabilitation Calendar – This functionality presents the game statistics in a calendar view for the therapists to track the patient's rehabilitation activities.
Communication Service:
This module consists of the functionalities related to the communication between the patient and the therapists.
Besides, above main modules the web-interface also provides the following sub-modules.
User Profile Management - This module consists of the functionalities to visit and update the personal profile of the therapists and caregivers.
Games Inventory - An inventory of the available games, with their full descriptions.
Equipment Inventory: An inventory of the available equipment, with their full descriptions

Family client
Overview on the family client
The Family client is a monitoring tool for family members or caregivers to support the patient’s rehabilitation plan by over viewing progress and most relevant information on therapy compliance of patients, as well as by communicating with therapists and clinicians in case of need.

Family client details
The Family client provides a subset of the features described above for the Therapist client. Specifically it includes:
• Basic features of the user management service: e.g. creating an account as a caregiver.
• Basic components of the Data Visualization Service, including the Rehabilitation Calendar to monitor exercises assigned to patient by the clinicians and possible intervention in case the patient is missing or skipping exercises assigned.
• Communication Service
• Games Inventory
• Equipment Inventory
This choice of features provided was motivated by the need to offer caregiver an intuitive tool to support motivation and compliance of patient with the rehabilitation therapy assigned and the possibility of supporting the patient with the setting up and use of the rehabilitation infrastructure in home environments.
Back-end system
The back-end system retrieves data from the Central Information Storage (CIS) that stores the raw data received from Game Component (GC) and Signal Interpretation Component (SIC) for each game session. Data is processed by algorithms whose tasks are to highlight the problems during the gameplay like moments of high excitement or else to understand if the game intensity is too low or too high for the patient. To perform this kind of computation, all the data is stored in the back-end system. The back-end system output is called “summarization” and it is stored in the CIS with the right format as required by the Therapist Client interface.
The back-end system is developed with the idea of being able to run on a server completely unattended: no interaction is required or anyhow possible.

Security Aspects of internal communication
The Rehab@Home platform is potentially a distributed system even at the patients location due to the use of services and sensors that are located at different positions and maybe also on the body of the patient.
Some sensors are not able to create an encrypted transmission for their data (such as the Wiimote and the Kinect), but intercepting these data streams is technically challenging.
Unencrypted sensor data could be a privacy problem if biological data is transmitted over a generic network (Wireless Lan, Ethernet) before it reaches the Rehab@Home components. This data is potentially easy to capture and could be associated to the user. If this is considered a privacy problem, the data processing should avoid providing identifying information along the transmission and use (computer generated) pseudonyms to identify the user internally. This method is however ineffective if only a few users are present. A correlation of transmission times and other activities would make the reconstruction of the pseudonym into an identifier trivial.
In general, data protection should start as early as possible and the local network should not be considered trustworthy. A best effort should be made to avoid identifying information and the use of encryption – if computing power allows it – is always strongly suggested when personal data is sent.
Data processing and operational infrastructure
Features to support relevant physical and physiological parameters acquisition and their processing, user-machine interaction, creation of an immersive rehabilitation virtual environment, remote assistance, communication network, serious games prompting and execution as well as feedback recording are considered. In order to guarantee interoperability under the REHAB@HOME operational infrastructure, suitable data models were defined and implemented, to be used by the sub-systems to exchange data and information through their interfaces.
From the practical point of view the development approach in REHAB@HOME was based as much as possible on the identification and integration of suitable existing HW/SW components into an innovative solution. Therefore limited effort was spent into the development of completely new technologies and, once the specification and design phase was sufficiently advanced, a suitable set of COTS (components off-the-shelf) was identified.
The Rehab@Home Operational Infrastructure functioning essentially relies on the acquisition, processing, exchange and interpretation of a large set of heterogeneous data and information coming from: existing clinical data records, rehabilitation workflow structure, user-system interaction, explicit user feedback, basic information about expected and actual rehabilitation progress, biophysical sensors. This is a huge amount of raw input data to the system, which has limited value if at least the following information relevant for the rehabilitation process is not properly extracted and managed. The aim was to identify which information is relevant and useful in the management and treatment of the patient’s condition. Communication and feedback between various actors have been designed: from patient/ individual to medical centre; from medical centre that analyses the acquired data to therapist; and back to the patient/ individual from either the portable system itself or the doctor or the medical centre (e.g. in the form of personalized feedback and guidance to the patient, adjusted treatment via closed loop rehabilitation therapy, control of therapy devices, etc.).
The main objective of Rehab@Home project was to transform the patient’s home in a place where physical and cognitive rehabilitation processes can be performed in a controlled way.
The patient will not only be in contact with experts of the rehabilitation centre providing guidance and feedback, but will also enjoy the participation in a sort of virtual gym, to increase inclusion and motivation.

The main evaluation results
Overview of evaluation
Overall, it can be concluded that the devices and games proposed to patients, caregivers and therapists were positively accepted. Several indications for improvements were also provided, mainly addressing the need for supporting calibration of the solutions to the range of motion and specific needs of patients, customization of the games, visual and audio elements of the games, motivational strategies to better engage patients and provide feedback on progress during therapy, support for collaborative forms of play. Further conceptual and usability advancement of the clinical interface for therapists were also uncovered during the prototype evaluation.

User acceptance evaluation
The user acceptance of the REHAB@HOME solution prototyped was iteratively tested during the first two years of the project by means of two pilot studies involving small groups of patients, representative of our target user group, including also their therapists and caregivers. These pilot experimentations were conducted by deploying initial prototypes of the REHAB@HOME components, not yet integrated in a final solution. Results of these evaluations are reported in D7.2 (sections 2-3)
The user acceptance evaluation conducted during the third year project trials was carried out on the final integrated demonstrator, based on a LivingLab approach.
Each trial site, after approval of the study by their Ethics Board, involved a sample of 8-12 patients (balanced in terms of gender and age range) in the study, including post-stroke patients and patients affected by other types of cognitive-motor impairments causing difficulties with ADL. The trials’ participants were selected by the local clinical staff, based on their suitability to the inclusion criteria (e.g. post-stroke, Multiple Sclerosis patients with upper body motor impairments, not wearing pace-makers devices). They belonged to outpatient units (e.g. visiting the rehabilitation facility 3 times a week for therapy sessions) or patients already involved in home-based rehabilitation programs. In the latter case, FDCGO involved both patients living in small towns and cities. NTGB installed Rehab@Home demonstrator at their premises (both at training rooms and at patient's rooms) and conducted regular rehabilitation sessions using the Rehab@Home devices. They also encouraged patients to use the devices 'privately' on their rooms in the evenings. Also, visiting relatives were introduced to the devices and integrated in the upcoming home rehabilitation process.
The trial sample also involved ten members of the professional staff (e.g. physicians and therapists) supervising the rehabilitation program of the patient, and caregivers. The Rehab@Home functionalities deployed and tested during the trial consisted of the Patient Station, including the user friendly gaming platforms for home environments, the Therapist Station for remote monitoring of the execution of plans of care assigned by clinicians, the Family Station, including the features for supporting the patient’s motivation and progress over therapy by caregivers or family members.
The final trial was conducted by the two rehabilitation clinics (FDCGO and NTGB) by following the same evaluation protocol and procedure (see D7.2). The patients performed 12 therapy sessions supported by the Patient Station. After each session the patient filled in a Post-Session Questionnaire including User Experience/satisfaction questions.
The therapists involved in the trial were also asked to fill in the SUS Questionnaire at the end of the trial to assess the level of usability of the Therapist Station.
Overall, 19 patients were invited to use the REHAB@HOME demonstrator at FDCGO (11 patients) and NTGB (8 patients) facilities over 12 consecutive sessions.
Patients’ age range was 28-86 (Mean = 55.64); the patients who completed the trials sessions were 10 females and 5 males.
The participation and engagement with the 12 session’s trial was quite good at FDCGO, reporting only one patient dropout, and more difficult at NTGB where three patients had some problems in completing the game-based treatment assigned.
The Intention to Use the REHAB@HOME system for the patients who completed the trials sessions was very positive before the trial and remained positive for most of participants also after the trial end. This shows that patients perceived the solution used as a feasible tool and setup for performing rehabilitation treatments at home in connection with their therapists’ supervision.
REHAB@HOME also contributed to increase or maintain patients’ motivation towards performing rehabilitation, since only 2 out of 15 patients showed a decrease in motivation after having completed the trial sessions.
The trials results showed a very positive outcome in terms of usability and user satisfaction with the solution proposed (Figure 5). The overall user experience with the system was assessed as very good by patients over all the 12 sessions carried out, showing that the level of maturity of the integrated prototype released is quite good to support future deployments in real-life settings.
Regarding the Therapist Station SUS assessment, 8 therapists (3 Female, 5 Males; Mean age=33, SD=9.62) filled in the questionnaire. Results showed that 3 out of 8 therapists found the component usable with a score above the average of 68. The remaining scores were below average, showing that some improvements to the usability of the component features and look&feel are still needed. The Mean score obtained was 58 (so only 10 points below average). From this we can derive that the general assessment of the Therapist component by most of the clinicians who used it during the trial was also positive, although for some therapists some improvements in terms of usability and look&feel of some features were still required.
Figure 5: Mean values of patients Usability and Satisfaction assessments after each of the 12 trial sessions [Likert scale 1-5, 5=most positive side] (see attachment)
Therapeutic effectiveness evaluation
Pilot studies were carried out in Fondazione Don Carlo Gnocchi Onlus (FDCGO), Milan, Italy and in NTGB in Gmunden, Austria in three main periods. A first pilot, a second pilot and a pilot evaluation of the therapeutic effectiveness of the serious games were carried out. In all cases the participants were persons Post-stroke or with Multiple Sclerosis with motor difficulties of the upper body.

The aim of the first pilot was to test a set of game-based solutions for in-home rehabilitation of patients within a simple exploratory and interactive session supported by a range of different technological platforms and games. After this initial testing phase with persons with neurological disorders which allowed the assessment of the usability and ergonomic qualities of the solutions proposed, and the eliciting and understanding of the patients’ needs and rehabilitation constraints, initial solutions were refined and a more comprehensive set of functionalities was developed for the next pilot phase.

The second pilot was meant to assess if usability and motivation related problems identified in the game solutions evaluated during the first pilot had been properly addressed and solved with the enhanced versions developed during the second year. This second testing was also aimed to support the final integration of the games and clients of the REHAB@HOME platform in preparation of their deployment and evaluation in the third year trials. The second pilot included a number of patients from both FDCGO and NTGB that tested the developed games and gave feedback through satisfaction and motivational indexes. The aim of the game environments proposed were to support rehabilitation of movements of arms, hands over the horizontal plane (e.g. opening/closing of hand, reaching movements) including many repetitions of task to facilitate motor learning.
Before each individual session the patient and caregivers/relative were welcomed by the experimenter and provided with an Information Sheet describing the aim of the study and a Consent form to be signed by the patient.

The last pilot study of therapeutic effectiveness was carried out in 2015 in FDGCO and in NTGB, 18 persons (11 with MS, 7 Post-stroke) were recruited, 3 dropped out of the study after the first couple of treatments; 15 persons Post-stroke (N = 5) and with MS (N=10) finished all 12 sessions (mean age 58,73, SD 12,78). All were provided with an information Sheet describing the aims of the study and signed a Consent form.
The participants were evaluated with validated clinical scales for functional abilities and perception of health, with motivational and satisfaction indexes and were classified through an International Classification of Health (ICF) core set preceding and after 12 rehabilitation sessions of the serious games playing.

The serious games were played utilizing Kinect sensors; each session lasted 30-40 minutes. The participants played 5 days a week until 12 sessions had been played. The gaming environment was adapted as much as possible to be playable by the participant, given their ability to control the motion of their upper body. With increase in ability the games were made progressively more demanding.

Results of the clinical evaluation before and after the 12 rehabilitation sessions showed that there was an improvement in functional abilities and fine hand use (Box and Block Test, Nine hole peg test). Further, evaluation of health perception (EQ 5D-5L) and the participants perception of wellbeing (Short Form 12) revealed an improvement in those domains following rehabilitation with serious games. These results were corroborated by reduction in severity of impairment and activity limitations as classified through the ICF core set. In general differences observed through the ICF core set following rehabilitation were small, but all showed improvements in the various domains. As an example, Exercise Tolerance increased enough to change the qualifier status, from very limited exercise tolerance to moderate impairment of exercise tolerance. This was reflected also in the improvement of the activity domain of walking and moving around that before treatment were moderately limited in the patients’ group and after treatment was mildly limited. Moreover, also fine use of hand was improved.

Overall, it can be concluded that the devices and games proposed to participants were positively accepted. The integrated solution deployed in the final trials assessment was very positively received by patients in terms of user experience and motivation to use, with the participants showing also improvements produced in terms of functional abilities of the treated arm/hand of patient and also regarding perceived health status.

Potential Impact:
The potential impact
Product description
Defining an exploitation plan requires the characterization of the products that will be sold in the future under the Rehab@Home project. Rehab@Home is, in essence, a Rehabilitation and Motivation System, specially optimized for persons suffering from motor impairments of the upper body and no or mild cognitive impairments following stroke or Multiple Sclerosis (MS). The goal of rehabilitation is to help survivors and patients become as independent as possible and to attain the best possible quality of life.
Rehab@Home aims at encouraging continuance (medium and long-term) rehabilitation that could take place at the patient’s home instead of at a dedicated place like gyms or health care structures. The system does so by providing controlled home-based physical training as well as follows up by the health team. The patient is in contact with experts in the rehabilitation center providing guidance and feedback. The training is developed to enhance the fitness of the patient in an interactive way, by form of a 'Serious Game', which imitates day to day activities. These games are based not only on scientific findings regarding the progress of physical impairment, but also on game theory and gamification, providing incentives and rewards within the framework of the game itself, and the wider social peer group (comparison with other players, achievements, etc.).
The Rehab@Home system is an integration of a set of easy-to-use technical equipment that the patient can use without an expert supervision in the rehabilitation centre, but independently at home, with the participation of caregivers, family members to facilitate patient’s inclusion and motivation.
The system provides the opportunity to monitor health related indicators, (e.g. pulse, subjective pain level) and thus, ensure the wellbeing of people in a non-invasive way, providing the maximum support when necessary. This opportunity is given to professional caregivers and family\friends as well, by providing a station for the healthcare team and the family (caregivers). In the case of professional caregivers the system gives the important option of the ability to organize a large number of patients, to easily set-up and manage sessions for them, and to monitor the progression by analysing the data obtained in the Serious Games. Rehab@Home is designed in a fashion that allows it to be adaptable to the specific requirements of the patient.
Target customer tailoring of Rehab@Home
Two main sectors of customers have been identified for the Rehab@Home system: professional and family care providers. As these two types have fundamentally different needs, a successful home rehabilitation system has to satisfy both, or the packages to be generated for them are not as similar as would initially be expected. Especially, the professional care providers will require a dedicated service undertaken by IT experts to help them incorporate the Rehab@Home system into their established IT infrastructure. This especially entails the synchronization of patient data, which for some institutions will be comprised of a huge set of sub-data and meta-information. The handling of the access rights, the ability to pre-define sets of actions and the ease of administration will all be of great relevance to the professional care provider. The family care provider, on the other hand, has no need to manage a high number of clients with his Rehab@Home system. The quality of the tutorials and the ease of use are more important criteria. Rehab@Home was developed to provide tailored solutions satisfying the needs of both target customer groups. Both costumers were involved in the pilots and were interviewed. The solutions that the system suggests have two different stations for each customer. A third type of customer was detected during the project – the end-users themselves. The Rehab@Home system could also be used for fitness purposes. In this case, a patient himself can choose to buy the system. The consortium decided to focus on the professional caregiver as they are the only ones that can offer a follow-up on the rehabilitation plan, which is an important feature of the Rehab@Home system.
Additionally we have marked telehealth technical systems providers\distributes as another optionally customer. As we will sign a contract with one or several distributes who work in the health segment and have experience in selling healthcare systems to healthcare institutions. Their need is to have a stable, quality systems with a price which the market can bar and profitable for them. Beyond that, if the system will answer the needs of its end users it will be more sellable and distributes would want to collaborate with us.
Rehab@Home exploitation scenario
Exploitation scenarios within Rehab@Home can relate to two different aspects of the projects results. The one type of result is the know-how and experiences gathered within the project, the other type are the concrete products. The first can be used within consultancy the second can be sold directly to customers.
The second comprises of 3 entities: The Rehab@Home system provider, the clinic which are the Rehab@Home clients and the patients (end-users) which are the clinic clients.
The system provider will sell the system and several packages to use at the patients homes to the clinic and will provide technical support needed for installation. The technical support and any start-up assistance needed at the patient's home will be provided by a sub-contractor in each marketing country. The sub-contractor will charge additional fees including system updates and training. The home package will include a "smart box" with the required software and connection wiring / unwired connection. Those packages will be bought by the clinics so they can decide if to rent them to the patients or give the patients the package as part of the clinic health service. The clinics would be instructed to do the first sessions with the patients at the clinic so they will learn how to use the system and be instructed how to install the system at home. The end-users can chose to pay additional fee to the sup-contractor and have a technician install the system in their home.
The impact of telehealth products for stroke or MS patients with upper body motor impairments
Declining fertility rates combined with steady improvements in life expectancy over the latter half of the 20th century have produced dramatic growth in the world's elderly population. People aged 65 and over now comprise a greater share of the world's population than ever before, and this proportion will increase during the 21st century.
In Europe, the population growth has slowed down in recent decades to a rate of 0.3% in 2003 (Eurostat (2004): Eurostat yearbook 2004. The statistical guide to European Data 1992-2002. Luxembourg). On the other hand, life expectancy has continuously increased. In the last decade alone, life expectancy at birth has risen by almost three years in the 25 EU countries, reaching 75 years for men and 81 years for women in 2002. Those aged 65 years or over will account for 29.5 % of the EU-27’s population by 2060 (17.5 % in 2011). These illustrate the unprecedented demographic shift the European Union is facing today.
A longer life does not always mean a healthy life. With the increasing age long and severe illnesses are often appearing, for example stroke or physical impairments. To adequately address these new challenges, both quantitatively (rising number of elderly people in need of assistance) and qualitatively (higher demand by the elderly for comfortable and self-determined living), telehealth care is a promising solution. This is especially true for those people that only have mild disabilities.
In addition with the increasing demand for health care the health care system is expected to collapse under the burden of the manpower and costs of this new challenge. Telehealth could take a big part in this solution. Telehealth care systems are mostly remote monitoring and care requires less manpower.
Market segment for the Rehab@Home product
The main market for the Rehab@Home technology will be in the tele-healthcare gaming market. Telehealth is a medium of communication between patients and doctors. Telehealth enables doctors to stay in touch with their patients, monitor their health and provide consultation if need arises.
At the moment, the market is still in its infancy and thus penetration is low for telecare technology, presenting a promising niche for companies providing such solutions. Healthcare gaming market is rapidly growing with many clinical studies supporting the benefits of gaming to the elderly population and disabled. The home healthcare market is poised to reach USD 349.8 billion by 2020 from USD 227.5 billion in 2015, growing at a CAGR (Compound Annual Growth Rate) of 9.0% from 2015 to 2020. Of this, the telemedicine dedicated device and software markets are anticipated to reach $2.9 billion by 2019. The home telehealth market is expected to grow at the highest CAGR in the coming five years. Rising awareness regarding the convenience and cost-effectiveness of home healthcare products & services, the increasing adoption of telecommunication in healthcare and government initiatives to promote home healthcare is contributing to the growth of this market. According to Jurriaan Van Rijswijk, chairman of the Games for Health conference, the industry as a whole was worth some $1.2 billion in 2010, and is estimated to grow to $10 billion by 2015.

Rehab@Home Exploitation Plan
Demand for the Rehab@Home offer for post-stroke clients
The Rehab@Home solution can target several different populations in need for rehabilitation: Stroke patients, Multiple Sclerosis patients, ALS (Amyotrophic Lateral Sclerosis) patients and several other diseases. The pilots conducted thus far targeted patients with low disability or difficulties with movements of the upper body, mainly post stroke patients.
The prevalence of stroke events is expected to increase across the globe (D. Mukherjee & PG Chirag. "Epidemiology and the Global Burden of Stroke", World Neurosurg, 2011, 76, 6S:S85-S90). The number of stroke events in Europe is projected to rise from 1.1 million in 2000 to 1.5 million per year by 2025, largely due to the ageing population (T. Truelsen, B. Piechowski-Jozwiak, R. Bonita et al. Stroke incidence and prevalence in Europe: a review of available data. European Journal of Neurology, 2006, 13: 581–598). In the EU27 countries, the annual economic cost of stroke is an estimated €27 billion: €18.5 billion (68.5%) for direct costs and €8.5 billion (31.5%) for indirect costs. An additional €11.1 billion is calculated for the value of informal care (10 British Geriatrics Society. Human and economic burden of stroke. Age and Ageing, 2009, 38: 4–5). The per capita costs associated with stroke in 2006 varies greatly between EU countries, from 5 € per person (Malta) to 78€ per person (The Netherlands) (S. Allender, P. Scarborough, V. Peto et al. "European Cardiovascular Disease Statistics", 2008 Edition). The high level of variance in stroke care costs per capita indicate that perhaps marketing efforts should be adjusted to fit to such data, as countries with high costs per capita should be targeted first (UK, Germany, Finland, Sweden, Italy, Greece and Austria). Furthermore, a recent study warned that stroke is affecting young people more so than before. The study reported a 25 per cent increase in the number of stroke cases among people aged 20 to 64 years old in the past two decades worldwide (V.L. Feigin, M.H. Forouzanfar, R. Krishnamurthi, G.A Mensah ,M. Connor, D.A. Bennett, A.E. Moran, R.L Sacco, L. Anderson, T. Truelsen, M.O'Donnell N. Venketasubramanian, S. Barker-Collo, C.M.M. Lawes, W. Wang, Y. Shinohara, E. Witt, M. Ezzati, M. Naghavi, C. Murray. "Global and regional burden of stroke during 1990–2010: findings from the Global Burden of Disease Study", The Lancet., Vol. 383, Issue 9913, Pages 245-255, 2014).
For the estimation of the market penetration of the Rehab@Home system we are using an optimistic penetration of 10%, a neutral penetration of 6% and in a pessimistic case of 3% based on the number of stroke patient from 2009 for the four partners' countries, see Table 1.

Table 1: Market penetration by country for post stroke patients (see attachment)

Business model canvas for the Rehab@Home system
The business model canvas is a strategic tool in examining and evaluating the integral parts in a companies offering. It allows a segmented approach towards identifying the key components of the business model and provides an overview of their interaction and interrelations. The Rehab@Home consortium aims at the commercialization structure as described below in Figure 6.
The commercialization structure contains the “core” project results, i.e. the Rehab@Home system as such. We have identified the rehabilitation institutes and physician (who take care of patients suffering from motor impairments of the upper body and no or mild cognitive impairments fallowing stroke or Multiple Sclerosis (MS)) as customers, in addition to the distributors of this kind of systems. An individual value proposition for each segment has been envisioned. While the first two customers seem very similar they see the value they will assign to the Rehab@Home offering from a different angle. The physicians will see the most value generated by the system in the ability discharge their patients earlier from the hospital while counting to closely follow up on them whenever it is convenient for the physicians. In addition, they will have a serious games system to offer their patients which will motivate them to continue their rehabilitation and will at least prevent a progression of their rehabilitation state. The rehabilitation institutes share many of the same assigned values to the Rehab@Home system, but might have slightly different motivations in doing so. The time constraints imposed on care service personnel through sheer economic necessity are considerable, and a system that will allow them to relocate some of the work they usually have to do to their clients (e.g. different check-ups and rehabilitation sessions) will significantly increase the economic feasibility of any care service provider. Coupled with the possibility to integrate the Rehab@Home system into an existing IT framework of a caretaker will provide considerable incentive to care service providers to advocate the benefits of Rehab@Home to their clients directly. Due to the Rehab@Home system, they can discharge the patients earlier while taking care of more patients at once, which will lower the cost per patient and in some countries raise their total government financing. While this might seem selfish at first, they will offer their client the opportunity to go home earlier and still receive a close follow up without commuting to the institution. The distributors would have a complementary system to their other products and an open source platform to offer their cliental, which they and their client could integrate with the other systems. The primary channels identified by us for spreading information about the Rehab@Home system and presumably most valuable channel will be telehealth systems providers\distributors. Telehealth systems providers are also defined as key partners and customers. Rehabilitation professional print media and professional conferences are also a promising channel with which to reach the target physicians and rehabilitation institutions managers. Of course, word of mouth is always a viable source to proliferate the knowledge of a company’s offering, especially considering a non-techno savvy group. Additional value proposition for the distributors would be forms and internet sites presenting systems like Rehab@Home.
For key partners, as mentioned above, the distributors and technical telecare service providers are the most prominent partners. Professional caregivers are also our partner in improving the system and turning the system into a commonly used one. All of these have a vested interest in the Rehab@Home system, and are integral to the overall solution as well as prominent in spreading information on the system. Additionally, key partners will provide the required hardware for the Rehab@Home system (computers, Kinect, sensors).
As for the key activities required for the Rehab@Home solution, platform management, offering services related to the platform (integration, technical updates and training services for instance) at first by the consortium and later by a sub-contractor and the advertising while presenting the platform itself (i.e. the Rehab@Home system) are considered paramount. The key resources are comprised of the physical IT infrastructure, the IPR for the software solution, the personnel of the healthcare provider (which is a resource contributed by a key partner) and the system support. This business canvas will lead to the cost structure of the business plan.
Figure 6: Business model canvas for the first tier of the commercialization model (see attachement)

Rehab@Home Exit Strategy
Rehab@Home Consortium's aim is to enter the market within two years after the project’s end.
In order to do so, a commercialisation phase needs to be performed by transforming the Rehab@Home demonstrator into the fully qualified Rehab@Home product. This phase will concentrate on enhancements to the technical product, its design, and on implementation of the related services. The REHAB@HOME Company via the Rehab@Home developing partners will be active in the German speaking countries and in Italy. In the German speaking countries, the marketing activities can be bundled, therefore less personnel will be necessary for the activities in Austria and in Germany.
Marketing activities calculated in the business plan include development of an IT distribution network. This network will consist of IT partners in the health segment distributing the Rehab@Home product to their customer base and are capable of providing the necessary maintenance and services for it.
The development partners Netural in Austria, Imaginary, Create-Net and University of Genova in Italy, as well as Bremen University in Germany will improve functionality and product maturity during a post project development phase.
The medical partners FDCGO in Italy and NTGB in Austria will have a demonstrator set up all along the two year phase and as part of this they will continue the validation of the system with their patients.
During the qualification programme for IT partners the personnel of all involved partners will be trained with all components of the system, teaching installation and use of the system. The personal of the technology partners will also be trained with knowhow regarding system maintenance and solving potential problems of clients and professional and non-professional care givers. These courses will start during the second year.
Furthermore, during the second year an IT partner hotline will be implemented giving support to the IT partner network in case of IT problems encountered that require help by the developers. The IT partners will be responsible for this until there will be an agreement with a subcontractor, within the two years.
To reach this goal there are several challenges to overcome:
To reach this goal there are several challenges to overcome:
• A legal organisation, called REHAB@HOME has to be founded by the consortium, exploiting the results of the Rehab@Home project.
• Agreement has to be reached with the members not interested in participating how their IP can be made available to REHAB@HOME.
• A plan on how to proceed after the end of the project with the technical side and validation of the Rehab@Home system.
• Extensive investments will be necessary to perform the commercialisation phase in the two years period after Rehab@Home‘s end. The consortium partners, mostly non - profit organizations, do not have the necessary financial capacity for the commercialisation phase. Therefore, an investor has to be found for commercialisation of the project results.
• To reach this, participation of Rehab@Home partners in Serious Games & rehabilitation technology events has to continue.
The Rehab@Home consortium will invest the coming up months in order to expand the Rehab@Home stakeholders and collaborators circle and to find an investor the consortium has done and will continue doing several activates, such as hosting demonstrations, publishing articles & book chapters, establishing connections with rehabilitation institutes, distracters, insurance companies and other stakeholders.
If the Rehab@Home developers would have the chance to finalise their products within this phase the validation of the Rehab@Home system will be expended and the configuration of the product can be tested in different countries under different application conditions.
Imaginary always intended to exploit the suite of Rehab@Home games on both the health and the care markets. For this purpose several contacts were already made during the life time of the project itself, very many demos were organised and the suite of games was even distributed for free testing in some hospitals in different countries.
While there are difficulties with many hospitals created mainly by bureaucracy (e.g. certifications as medical device), some promising directions were identified. Mainly these can be summarized as follows:
• There is interest in the health sector to have a children version of the games
• The games can be used also for other objectives/medical sectors, e.g. for synchronization of eye movement and grasp (this opens other potential market space)
• The care sector is very interested in such solutions not only for the medical objective of rehabilitation, but also for “intelligent” entertainment with psychologists, who can exploit the cognitive elements and build social activities around this kind of games; they do not have any obligation with “medical devices” as we are talking with private groups
In order to progress with exploitation work, several activities have been taking place at IMA since the end of the project, both in technical as well as in commercial terms:
• A proposal of children friendly interfaces (for the same game mechanic) has already been designed, which will be used together with a set of questions for participatory design with hospitalized children of different age groups: hospitals interested in collaborating on this research have already been identified
• The first plan of raising the cognitive level within the games, in a way that the doctor can set it (similarly to what is happening to the physical movement) was made, according to the wishes and needs of several potential customers (both clinics and care homes). Development of this part will start asap
• Many more contacts have been made and at present there are test installations in Germany (children hospital) and Greece, while in Holland a sponsoring action by a supermarket is collecting money for a children hospital to run a clinical trial and while a children hospital in Italy is buying the equipment for 2 sites.
Following results were already reached by the end of October 2015:
• A distribution agreement was signed with 2 companies in Singapore
• A partnership with an Italian multinational company selling a hospital system with patient record worldwide, who is interested in integrating the games into their system, was signed. A dialogue with an Italian multinational company leader in telemedicine services has started with the same objective.
• The SEGESTA group of Italian care homes (which is part of the French Korian group) has decided to adopt the suite of games in their 60 care homes. By the end of 2015 the first 3 will be installed. A plan for 2016 activities will be developed soon. A contract will be signed very soon.
• IMA has been invited to a mission to Chongqing, China for the end of November 2015 organised by UK Trade and Investment to showcase the games and discuss with companies organizing health and care facilities and services there locally their adoption. Organization for this is progressing.
Business plan
In order to provide a mature product to the general public with the necessary channels, infrastructure and personnel in place will cost money before profits will be generated. We assume that by 2019, a profit will be generated p.a. and that 2022 the return of invest will be reached. If the insurance companies will support use of Rehab@Home like software systems, the ROI (return of investment) of the business plan presented will be achieved earlier. This, due to reduced prices for the Rehab@Home system, will lead to an increased demand and eventually shortening Time-To Market significantly. The Rehab@Home Consortium will continue negotiating with insurance companies regarding reimbursement of Tele-rehabilitation.
Please note that, as is common for software selling companies, for example, the installation, training a service portion will be taken over by IT partners, which will be subjected to a verification and qualification program that will ensure a high standard of quality. All in all, the revenues will be generating from hardware sales (using the parameters number of clients and price HW sale), installation, training and service (number of clients times price, later taken over by IT partners), integration projects for professional caregivers (software development for integration into existing IT infrastructure and calculated by number of such projects time their cost) and monthly fees for professional caregiver (number of clients time fee for customers, number times organisational units for professional caregivers, i.e. the latter fee is once per entity). The installation, training and service segment will be performed by IT partners after the first three year period, at which point the fees for the qualification and certification program will also be providing revenue.
The costs are comprised of personnel costs (yearly income multiplied by full time equivalents) for marketing, post-project development, to conduct the qualification program, implementation IT partner hotline, hotline and administrative staff as well as equipment cost (both infrastructure and sellable product) and cost of the personal working tool.
The main dissemination activities
The consortium was very active in disseminating the project idea and later on the project results. At the beginning of the project the partners agreed on a dissemination plan. This plan was monitored and most of the actions were conducted. The project partners gave internal demonstration events to inform their employees about the project and gain useful feedback for the internal project team. The project description was also implemented in each partner’s intranet. A project website was curated as a communication tool and kept updated with the latest news of the project to reach a broader public. Facebook and Twitter accounts were created to spread the project news. The website acts as an overview and repository of the information generated within the project. This can include, but is not limited to, posters presented at conferences, links to relevant papers and digital versions of the flyers or to interesting conferences. The project newsletters are also published there and used to supply interested readers with insights into the motivation and goals of the participants. The intention was to edit the newsletter in a regular way regarding the information about the project progress. During the project three newsletters were published. Presenting the motivation and results of the Rehab@Home project at European and worldwide conferences and workshops, fairs and exhibitions provided the opportunity to not only disseminate the project to a wide audience, but also enabled communication with other experts in the fields of healthcare and rehabilitation and the collection of feedback. Presentations were also a good first contact opportunity, paving the way for joint future commercial interests. Conferences of interest were for example the “MedinIsrael” conference in 2013 where the project started to gather first ideas and feedback about the project from medical staff and stakeholders. The “SIRAS” conference in Rome/Italy in November 2013, the Aging Wealth Conference in Modena/Italy in October 2014, the SeGaMED in December 2014 in Nice/France or the IEEE Conference in Leuven/Belgium in June 2015 are examples for this activity. The project was also represented at fairs like the CeBIT in Hanover/Germany 2015 at the “Serious Games Conference” there and the Fair “REHAB2015”. Educational courses for medical professionals were given at the “Italian Society for Stroke” in Savona/Italy in May 2015. Dissemination materials employed at these occasions were the project flyers in English and German language, a poster and a roll-up. The consortium created a project video to promote the project idea in another medium, which is also available on the project website. Articles about the project work were mentioned in several newspapers (print and online) in Italy and Israel and press releases were uploaded on partner websites. Examples are the Notiziario Europeo where the article “La Liguria in Europa” was published in July 2013 or the online publication in the newspaper “Il Sole 24 Ore” with the article “Serious Games, giochi per fare e per imparare” in December 2014. The online magazine “About Pharma” published several articles about the serious games developed within the project. The project is also part of the website. Besides the publications in non-scientific magazines and newspapers, the consortium also published in scientific journals, for example the article ”Rehab@Home: Ein EU Projekt zur nachhaltigen Rehabilitation mittels „Serious Games“ at the “7. Deutscher AAL-Kongress mit Ausstellung, 21. - 22. January 2014 in Berlin Wohnen – Pflege –Teilhabe – Besser leben durch Technik“ published with the ISBN number 978-3-8007-3574-7, or the article “Designing Meaningful Game Experiences for Rehabilitation and Sustainable Mobility Settings” at the EAI Endorsed Transactions on Ambient Systems” published with the following link: During the project two theses were written at the university of Bremen and a further two are planned in late 2015 and beginning of 2016.
Two showcases were performed during the project runtime to disseminate and exploit the project results. The first one was conducted in March 2014 where a selected audience was invited and the interim project results were demonstrated. Useful feedback was gained and connections were established for future dissemination and exploitation actions. The second showcase was performed as the main dissemination event of the project. It took place at the end of the project on September 2015th at Don Gnocchi Premises in Milan and the project findings were presented as an introduction to a roundtable about the adoption of enabling technologies, such as serious games, in medical practice. Panellist included a representative of the Italian Health Ministry, Medical Specialists, Healthcare Solution Providers and members of the Public Administration. More than 80 participants from Italy, Germany, UK, Spain, Greece, and Austria were attending this event; the demo area hosted solutions also from other EU projects, such as DOREMI, Pegaso, and Millenium Hospital. Imaginary participated in REHABILITY with the product they derived from the Rehab@Home games for the DigitalAward prize organized in Italy by AbutPharma. They registered the product to 2 categories: “Patients” – with the subcategory “supporting adherence to therapy” and the category “Enhancing healthcare organization”. They ranked in the first 3 out of 90 in the Patients category and... WON the second one!!!

A storify of the event can be found here:

List of Websites:
The project website's address:

Relevant contact details: Prof. Dr. Michael Lawo, Universität Bremen, Bibliothekstrasse 1, 28359 Bremen, Germany