1 Introduction

ABLE is a collaborative project, uniting researchers across health science, computer science, neuroscience and humanities to design experiences for frail older adults to enhance cognitive, physical, and emotional health. In this project, we employ a design thinking approach to develop an interactive exercise platform to tackle the growing needs of community and home dwelling older adults and their caregivers. Our targeted populations are frail geriatric outpatients, many of whom also experience dementia, at St. Peter’s Hospital, Hamilton, Ontario (Canada) and frail seniors in need of home-based rehabilitation services.

Frailty can expedite the pathway to disability due to physical deconditioning, impact objective and subjective health, and can reduce social participation. Art, music and game play are powerful therapeutic activities that motivate participation in physical activity and may have synergistic effects, enhancing cognitive, physical and emotional health. We are creating a variety of arts-based movement experiences using gesture based and biometric capture technologies to translate physical therapy into art engagement. In this experience, seniors with dementia and/or fragility will engage in physical therapy exercise with a care giver or family member that produces an effect; in other words, interactive movement produces a live digital painting, a musical composition or engages players in digital gaming with peers and family members. The project aims to advance the design of the Movement and Biometric Feedback Platform (“the Platform”) to produce artistic expression, gaming, movement, and interactions for frail seniors and to assess how the Platform impacts cognitive, physical, and emotional parameters in this population. In engaging these seniors in art-based practice and interaction, we anticipate the interface will offer physiological or rehabilitation therapy experiences that are pleasurable, which in turn, will be self-initiated and sustainable. In engaging participants in shared peer and intergenerational experiences that employ arts and play, we also seek to counter social isolation and enhance family and community bonds. Employing an interdisciplinary, design thinking approach, we incorporate diverse frail senior participants in the research design of movement and aesthetic solutions to ensure the platform is easy to use, pleasurable and effective.

2 Background

Frail, older adults with mobility impairments or who have fallen often receive a referral for home care physiotherapy to improve functional independence. Physiotherapy can help older adults improve their mobility through therapeutic exercises, enhancing strength and balance. [1] However, delivery of home care physiotherapy is often limited to three to five visits where the physiotherapists teach exercises and leave written instructions on how to complete them. Afterwards, older adults and their caregivers (e.g., personal support workers, spouses, family members, friends) are expected to continue exercising on their own. Consequently, older adults may stop exercising because they and their caregivers do not know how to do the exercises, are not motivated to exercise independently, or do not know how often to exercise to gain maximum benefits. As well, older adults residing in retirement homes increasingly experience significant cognitive and physical impairments. A recent study revealed that in retirement homes in the Hamilton-Niagara region, over 45% of residents had mild to moderate dementia. Many residents also had greater physical impairments than those living at home, had fallen recently, and demonstrated aggressive and wandering behavior. As a result, retirement home residents are at high risk for institutionalization in long-term care.

ABLE invites older adults with dementia in retirement and home residences to engage in physical exercise as meaningful art experience, that produces a virtual painting or sound score. Promising recent research suggests a synergistic effect arises from combined movement, social engagement and art practice. Engaging clients in dance and movement has been shown to improve emotional wellbeing, depression or anxiety [2], and art and dance stimulate memories in dementia clients, minimizing feelings of distress and disorientation, and improving health outcomes [3]. Making art creates more dramatic outcomes than simply viewing [4], enhancing agency and lessening social withdrawal and poor communication. [5]. A systematic review showed that using virtual reality games had significant positive effects on balance and mobility, and benefits for fear of falling, reaction time, and muscle strength compared to traditional exercise programs.

The ABLE platform responds to research showing that physical activity and movement reduces functional decline. As well, creative and social engagements have been shown to improve depressed mood and poor quality of life and decrease social isolation, all of which are associated with risk of functional decline and institutionalization. ABLE seeks to confront these problems by facilitating interaction with family members and care providers, reducing seniors’ boredom and agitation. With these objectives, ABLE aims to facilitate older adults to remain independent, while maximizing quality of life within their location of choice as long as possible, whether that is a retirement home or their own home.

Our initial ABLE prototype has been tested in various settings including Baycrest Hospital, Toronto. Our group employed participant feedback to develop arts-based experiences that engaged seniors with both fragility and dementia. The research revealed the seniors’ enthusiasm for engaging in the platform, in sustained physical engagement, and interest in varied digital art experiences. In this final iteration of the project, ABLE will provide (with video instruction) professional, scalable physical therapy exercises to address the needs of populations with fragility and dementia, to decrease pain, increase mobility, improve mood via an exercise experience that is social, pleasurable and packaged in a consumer-friendly plug and play form.

3 Hardware and Software Networking Interface

The project development occurs in Pulse Lab, McMaster University, which is outfitted with a movement space, and the ABLE Platform, including, biometric inputs, data projector, projection screen, speaker system and private Local Area Network (LAN). This wireless mobile Platform will also be set up at St. Peter’s Hospital (Hamilton, ON) for on-site client engagement and feasibility testing or in at home environments, by simply opening the app on a mobile phone and connecting it to the family television screen.

3.1 ABLE Platform Technical Specifications

The ABLE Platform has several component categories that work symbiotically. The flow of this data generation and feedback can be seen in Fig. 1. The biometric sensor arrays contain wearable wireless connectivity through Wi-Fi or Bluetooth that use principles of ergonomic design and wireless charging for increased ease of use (see Figs. 2 and 3). Data sonification and visualization is accomplished via several data processing programs that generate real-time audiovisual feedback for the participants to aid in their exercises and create an enjoyable experience. The LAN network created in a participant’s living space creates a seamless system that integrates a main television, and the participant’s, a caregiver’s or therapists’ mobile smart device. The mobile device is used as an interface for interaction or a secondary source of information for therapists and caregivers, revealing real-time data and other information to aid in rehabilitation.

Fig. 1.
figure 1

An outline of the participant experience when using the ABLE Platform

Full size image
Fig. 2.
figure 2

Adafruit flora series hardware to create a Bluetooth, Arduino based, motion tracker using an accelerometer and compass module. Photos: Adafruit.com

Full size image
Fig. 3.
figure 3

Adafruit feather series hardware to create a Wi-Fi, Arduino based, motion tracker and joy stick based controller using a high accuracy 9-DOF (Degrees of Freedom) board to track the subtle movements of a user in 9 degrees of motion. Photos: Adafruit.com

Full size image

4 Designing Rehabilitation for Motivation and Sustainability

ABLE takes into consideration barriers to exercise participation for frail, older adults with mobility impairment, and the lack of safe and accessible exercise facilities for this population. [4] While interactive technologies offer promising potential solutions to overcome these barriers, uncertainty remains around the feasibility of implementing interactive technology within the homes of frail, older adults. While it has been suggested that interactive technology can be used to easily engage hard to reach populations in exercise, [6, 7] few studies have explored the feasibility of using interactive technology with frail, older adults in their homes. Indeed, a recent systematic review identified that there is insufficient evidence to generate recommendations for using virtual reality games exclusively at home. [8] Another 2014 systematic review of Wii games8 identified only two studies that were conducted in the home environment. [9, 10] The authors called for a need to consider age, balance performance, comorbidities, and cognition when examining future interactive technology applications in the home environment. [11] Our study will fill this gap, by testing the feasibility of using interactive technology in the homes of frail, older adults.

Researchers have discovered interest by older adults in digitally based exercise programs. Research shows that computer-based, interactive technology, such as virtual reality and video games, and interactive technologies can improve adherence to, enjoyment, and outcomes of exercise. One study demonstrated 30% more attendance at exercise sessions when interactive video games were used compared with conventional exercise programs. [12] Researchers posit that interactive technology makes exercise more enjoyable since participants are directing their attention to the experience rather than the physical impairments they may be experiencing, [13] and suggests that motivation is key to improving functional outcomes. Indeed, interactive technology has also shown superior benefits to physical performance when compared with standard exercise programs. For example, a recent systematic review revealed that participating in computer-based virtual reality games had significant positive effects on balance and mobility, and helped to prevent fear of falling, to improve reaction time, and to lower extremity muscle strength compared to traditional balance and resistance exercise programs.

Finally, most interactive technology applied in the rehabilitation context offer sports-related activities not appropriate for most seniors; a 2014 systematic review showed that the most common Wii programs were soccer heading, slalom ski, and tight rope walking. [11] ABLE, differently, seeks to harness research showing that art and music are powerful therapeutic activities that motivate participation in physical activity and may have synergistic effects, enhancing cognitive, physical and emotional health. [5, 14] In engaging participants in art and music experiences created by physical movement (i.e., exercises), we expect to see added benefits, especially for older adults who identify more with and are better suited for arts-based (versus sports-based) experiences. The ABLE platform will provide opportunities for artistic expression in conjunction with physical movement, potentially increasing pleasure in, and in turn, the efficacy of this exercise platform for older adults in their homes.

5 The Interface Experience and Platform Advancements

The ABLE software application innovates by offering older adults with fragility or dementia a selection of engaging exercise and rehabilitation experiences. The ABLE platform consists of a wireless (clothes-clipped) sensor, a tablet, a mini-computer, and a screen (e.g., television). When the older adult moves, the wireless sensor transmits data to the mini-computer which produces visual effects (on the screen) or sound (on speakers) or game responses (on screen and speakers). A digital tablet is used by the older adult and/or family members to begin the interaction and to choose their desired exercise and art/game experience (e.g., painting, music making, or game play).

The app menu is designed to be clear and user friendly. The app will allow users to choose the type of physical therapy experience they wish to use and take part in interactive video training with their therapist of caregiver. The app will allow users to choose the numbers of users in the space ranging from one, to two players, or a team/gaming experience. The ABLE menu will also offer four types of interactions: musical or sound creation, digital painting, hybrid music/painting experience, and multi-person/intergenerational game. The app will feature a touch-based interface, offering a simple menu packaged in a clean visual design.

ABLE is an advancement in existing digital exercise systems, providing physical therapy regimes designed to meet the targeted physical and affective needs of seniors with fragility or dementia. Exercise experiences on the Nintendo Wii and games offered by Xbox Kinect, and other rehabilitation platforms provide sports experiences that are not designed or able to meet this population’s needs.

As users engage in their physical therapy experience in the space, the ABLE platform captures (and stores) gesture, exercise and movement data and transforms it into art and game “feedback.” Distinct therapy movements (raising arms, standing up, squatting, pressure ball use) create an effect—a brush stroke on a painting, adds percussion to a musical score, or enables interactive gameplay. Biometric sensors (e.g., heart rate monitor) can be added, capturing heart rate or breath data allowing less mobile individuals to trigger effect, for example, creating rhythm in a musical score or a painting stroke. ABLE can be used alone or interactively; it makes physical therapy engaging—in each “move”, the “player” makes a contribution in an art creation or a move in a game play. Finally, the app will capture the data from each physical therapy experience, enabling the participant to gauge and understand personal improvements in varied metrics (strength, mobility, agility, etc.) acquired with the use of ABLE over time. Finally, ABLE is affordable and has a low barrier to access, reducing the cost of physical therapy, allowing users to accurately remember exercises and practice them with caregivers or family. With its easy to use interface, ABLE will allow any family member or caregiver to click visual icons on a computer or tablet screen to select a desired exercise and art experience or game and get on with playing.

6 Data Capture and Analysis

Our in-progress, proof-of-concept study focuses on the development and feasibility of the Platform for frail older adults. A test cohort of approximately 20 older adults will be recruited and will pilot this platform over 6-months. Each older adult will receive three visits with a physiotherapist in their home. The first visit will be to prescribe the home exercise program and to familiarize the older adult with the technology. The exercises will be designed to improve functional mobility via challenging lower extremity strength and balance in a multicomponent exercise program. The most effective exercise programs for preventing falls for older adults include balance and lower extremity strengthening exercises. The exercises will be scaled to the physical functioning level of the participant, as determined by their performance on the baseline measures of balance and strength. For example, a squat exercise, which strengthens the quadriceps and hip extensors, can be scaled for lower functioning participants by having them start with standing up out of a chair using their arms. Scaling of this exercise would be standing without using their arms, standing from a higher chair to a standing from a lower chair, and doing a squat without weight and then adding weight. The physiotherapist will then visit one week, and one month later to troubleshoot any technological issues, and to progress the exercises where appropriate.

The ABLE platform is designed with gesture-based sensing and a wearable device able to capture a range of biometric data (heart rate, heart rhythm, breath, appendage placement, acceleration and speed, EEG, etc. In testing ABLE at-home and in clinic patients, physical therapists and our designers will use the platform to capture user data, and to chart progress in physical therapy regimes toward achieving greater balance, strength, agility, speed, range of motion and cognitive abilities. In forthcoming data capture and analysis, we will evaluate outcomes that measure improvements in frailty, lower extremity function, mobility, cognitive and emotional function, and activities of daily living, as well as user’s experience and pleasure in engaging in the exercises and the art-based experience.

7 Anticipated Outcomes and Benefits

Primarily, we seek to gauge adherence to the prescribed exercise protocol by participants recruited and retained in the pilot study. Secondary outcomes are physical performance and balance measured by The Short Physical Performance Battery (SPPB) [15], and the Balance Outcome Measure for Elder Rehabilitation (BOOMER) [16, 17]. The SPPB assess lower extremity function through measures of balance (timed static stance in feet together, semi-tandem and tandem with eyes open), gait speed, and the time to rise from a chair. The BOOMER is comprised of 4 measures: step test, Timed Up & Go test, Functional Reach Test, and Timed Static-Stance Feet-Together Eyes-Closed Test. The SPPB and the BOOMER will be measured at baseline and after three months by the research assistant in the participants’ home and were chosen as they represent tests that would typically be done by a home care physiotherapist. Finally, participants and their caregivers will provide feedback on the platform and participation in the pilot study via one-on-one qualitative interviews completed during the last study visit.

We also employ user interaction design and proof of concept testing in clinic and at home settings to assess user’s abilities to set up and use the ABLE platform independently. Via observation, field testing and family interviews, we will assess seniors’ and family/caregivers’ assessment of pleasure in the art-based experience, and value in the social engagement, as well as physical therapy impacts, and the potential that ABLE will encourage sustained use for varying individual of diverse ability and needs. Those results will enable our team to report on ABLE’s success in its 4 key objectives: decreasing social isolation and increasing family interaction; experiencing pleasure and creative engagement via art making or game play; adhering to regular, effective exercise or physical therapy; and enhancing mood for this population. As well, our study will assess ABLE’s impact in decreasing mood disorders and aggressive behavior in these populations, and to improve home and residential relations for participants. With those findings, we hope next to provide recommendations on how digital technologies such as ABLE can help to remedy the shortage of affordable and accessible health and rehabilitative care serves, and in turn, reduce the social and financial strain on families, residential institutions, and governmental health care systems created by fragility and dementia in our growing populations of seniors at home and in care.