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Advances in wearable technology for rehabilitation

Article  in  Studies in health technology and informatics · February 2009

DOI: 10.3233/978-1-60750-018-6-145 · Source: PubMed

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 Advances in Wearable Technology for
Rehabilitation
Paolo BONATOa,b
a
Department of Physical Medicine and Rehabilitation, Harvard Medical School,
Spaulding Rehabilitation Hospital, Boston MA, USA
b
Harvard-MIT Division of Health Science and Technology, Cambridge MA, USA

Abstract. Assessing the impact of rehabilitation interventions on the real life of

individuals is a key element of the decision-making process required to choose a
rehabilitation strategy. In the past, therapists and physicians inferred the
effectiveness of a given rehabilitation approach from observations performed in a
clinical setting and self-reports by patients. Recent developments in wearable
technology have provided tools to complement the information gathered by
rehabilitation personnel via patient’s direct observation and via interviews and
questionnaires. A new generation of wearable sensors and systems has emerged
that allows clinicians to gather measures in the home and community settings that
capture patients’ activity level and exercise compliance, the effectiveness of
pharmacological interventions, and the ability of patients to perform efficiently
specific motor tasks. Available unobtrusive sensors allow clinical personnel to
monitor patients’ movement and physiological data such as heart rate, respiratory
rate, and oxygen saturation. Cell phone technology and the widespread access to
the Internet provide means to implement systems designed to remotely monitor
patients’ status and optimize interventions based on individual responses to
different rehabilitation approaches. This chapter summarizes recent advances in
the field of wearable technology and presents examples of application of this
technology in rehabilitation.

Keywords. wearable technology, wireless communication, e-textile, telemedicine

1. The State of the Art in Wearable Technology

Significant progress in computer technologies, solid-state micro sensors, and

telecommunication has advanced the possibilities for individual health monitoring
systems. A variety of compact wearable sensors are available today and we expect that
more will be available in the near future. This technology has allowed researchers and
clinicians to pursue applications in which individuals are monitored in the home and
community settings [1].
Figure 1 shows a schematic representation of a wearable system as it can be
envisioned based on currently available wearable technology. A combination of
wireless sensors and sensors embedded in the person’s garments (e.g. a sensor suit) are
utilized to monitor data such as heart rate, respiratory rate, and movements of the limbs.
A data logger (e.g. a personal digital assistant, a cell phone) is utilized to store data and
transmit data and alerts to a remote clinical center or a caregiver according to the
application of interest. Clinical personnel have remote access to the monitoring system,
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Figure 1. Schematic representation of a wearable system to monitor individuals in the home and community
settings.
for instance, via a web-based application. The system is recharged at night via a
docking station that allows for fast communication with a remote clinical center by
means of an access point thus facilitating transfer of raw data and the performance of
maintenance tasks. This technology is bound to enable new telemedicine applications
[2] and to facilitate the implementation of the medical home concept [3].
Wearable devices can be divided into two categories: 1) garments with embedded
sensors and 2) body sensor networks. The idea of embedding sensors into garments
was first pursued by a research team at Georgia Institute of Technology led by
Dr. Sundaresan Jayaraman [4, 6]. Research work by this team eventually led to a
product referred to as Smart Shirt (Figure 2). The Smart Shirt is a wearable health
monitoring system by Sensatex, Inc., USA (http://www.sensatex.com/) that monitors
heart rate, body temperature, and motion of the trunk. The monitoring system is
designed as an undershirt with various sensors embedded within it. Data are transmitted
to a pager-size device attached to the waist portion of the shirt where it is sent via a
wireless gateway to the Internet and routed to a data server where the actual monitoring
occurs. The Smart Shirt incorporates a patented technology named “Wearable
Motherboard” which incorporates optical fibers, a data bus, a microphone, other
sensors, and a multifunction processor, all embedded in a basic textile grid that can be
laundered.
Figure 2. The Smart Shirt by Sensatex, Inc., USA, a garment with embedded sensors for physiological
function monitoring. (Reproduced with permission)

Figure 3. The MIThril is a platform of sensors and wearable computing technology to gather data in the field.
A description of the platform can be found at http://www.media.mit.edu/wearables/mithril/. (Reproduced
with permission)
 Following the pioneer work by the research team at Georgia Institute of
Technology, several companies and research groups pursued the development of
garments with embedded sensors. An example of the technology developed by
companies that manufacture wearable systems is the LifeShirt, by VivoMetrics. The
LifeShirt is a comfortable, washable “shirt” that contains numerous embedded sensors
that continuously monitor 30+ physiological signs of sickness and health. The list of
physiologic functions it monitors includes: ECG, respiration, BP, PO2, and posture.
Data from the sensors are recorded to a small belt-worn recorder where it is
encrypted and sent to VivoMetrics Data Center by cellular telecommunication. There it
is decrypted, scanned for artifacts, and posted in a database where summary reports can
be generated for the client.
In the research arena, several groups distinguished themselves for the originality of
their contributions. Among others, Dr. Sandy Pentland at Massachusetts Institute of
Technology developed the MIThril, [7, 9] an architecture that combines hardware and
software platforms as shown in Figure 3. The hardware combines computational,
sensing and networking in a clothing-integrated design. The software is a combination
of user interface elements and machine-learning tools built on the Linux operating
system. This architecture has been used by several mobile platforms for personal digital
assistants and cell phones to demonstrate that active pattern analysis of face-to-face
conversations and interactions within the workplace have the potential to improve the
functioning of the organization [10]. Researchers in Dr. Pentland’s laboratory are
currently exploring potential clinical applications of this technology.
Other examples of garments designed to monitor physiological functions are those
developed by Dr. Danilo De Rossi’s group at University of Pisa [11, 13] and Dr. Harry
Asada at Massachusetts Institute of Technology [14, 15]. These garments specifically
address the need for monitoring patients’ movements. However, as with all garment-
based solutions, they require patients to wear a special clothing item. While we believe
that this approach is necessary for very long-term monitoring (i.e. months to years), we
see the use of miniature wireless sensors as more practical when monitoring needs to
be achieved over shorter periods of time (i.e. a few days to a week).
Seminal work was performed toward the development of wearable wireless
sensors at the NASA’s Jet Propulsion Laboratory, Pasadena, CA where researchers
attempted to implement prototypes of sensor patches to record physiological data over
extended periods of time http://findarticles.com/p/articles/mi_qa3957/is_/ai_n8884077.
These non-invasive sensors were miniature biotelemetric units resembling adhesive
bandages (Figure 4). They were designed to communicate with a hand-held unit (i.e.
readout unit). The patches contained a noninvasive microelectromechanical sensor
integrated with electronic circuitry that transmitted a radio signal modulated by the
processed sensor output. The patch did not contain a battery. Instead, it contained a
circuit for extracting power from an incident radio beam that was present during
readout. For readout, a hand-held radio transceiver was positioned near the patch; the
transceiver transmitted the radio beam to the patch circuitry and received the modulated
radio signal transmitted from the patch. These sensors were proposed for use in
measuring temperature, heart rate, blood pressure, and other physiological parameters.
Following this exciting work, NASA initiated the Sensors 2000! program to develop
advanced sensors, biotelemetry systems, and data systems technology, including the
Sensor Pill, that can be swallowed to monitor the health status of the alimentary canal
and other organ systems.
Figure 4. Wearable sensor patch designed by Gisela Lin and William Tang as part of a project carried out at
NASA's Jet Propulsion Laboratory. (Reproduced with permission)
In the business sector, several companies took inspiration from the seminal work
achieved by researchers at NASA’s Jet Propulsion Laboratory and developed systems
based body sensor networks for commercialization. Among others, FitLinxx
http://www.fitlinxx.com/brand.htm has recently put on the market an ultra low-power
wireless personal area network that provides two-way radio communication that can
control and respond to sensors and actuators, as well as provide wireless connectivity
to the Internet via devices such as a cell phone, personal digital assistant or PC. Based
on this platform, FitLinxx has developed products for health monitoring that integrate
heart rate, blood pressure, a pedometer, and body weight data gathered using a special
weight scale. Similar products are offered by BodyMedia Inc
http://www.bodymedia.com/. BodyMedia’s products are centered on the SenseWear
Armband, a sleek, wireless, wearable body monitor that enables continuous
physiological and lifestyle data collection outside the lab environment. Worn on the
back of the upper arm, it utilizes a unique combination of sensors and technologies that
allows one to gather raw physiological data such as movement, heat flow, skin
temperature, near body ambient temperature, heart rate, and galvanic skin response.
The SenseWear Armband contains a 2-axis accelerometer, temperature sensors for
monitoring heat fluctuation, skin temperature, near body ambient temperature, galvanic
skin response, and heart rate received from a Polar Monitor system. The SenseWear
Armband can be worn continuously up to 3 days without recharging the battery (at
default sampling rate settings), and stores up to 5 days of continuous physiological and
lifestyle data. Research software is available to offer audio and tactile feedback for
reminders, targets, and alerts. Its ability to provide 2-way communication makes the
SenseWear Armband a hub for collecting data from other third-party products such as a
weight scale or a blood pressure cuff. The manufacturer promotes the product as
“eliminating the need for researchers and clinicians to administer and apply
cumbersome sensors to their research subjects.”
The research and development work summarized above is bound to facilitate the
development of new clinical applications in telemedicine [2]. However, a fundamental
limitation that hinders the application in rehabilitation of all commercially available
systems and the majority of the body sensor networks developed in the research field is
that most of the available systems are only suitable for managing data gathered at a
sampling rate of a few Hz per channel. The ideal sampling rate for applications in
rehabilitation ranges from 100 Hz for biomechanical data to 1 kHz for surface EMG
data. To our knowledge, only two research groups have focused on the development of
body sensor networks with the performance required by clinical applications in
rehabilitation. Dr. Emil Jovanov at University of Alabama [16] and Dr. Matt Welsh at
Harvard University [17, 18] developed body sensor networks that provide adequate
performance for application in rehabilitation. These groups developed complex data
management architectures with buffering and data transmission that occurs both in real
time as well as offline to meet the specifications of applications in rehabilitation. The
approaches developed by these researchers achieve high bandwidth in ways compatible
with the low-power consumption specification that needs to be met in order to allow
one to implement a wearable system for monitoring patients over days.
Researchers and clinicians with a focus on rehabilitation are demonstrating a
growing interest in the adoption of wearable technology when monitoring individuals
in the home and community settings is relevant to optimize outcomes of rehabilitation
interventions. Three major categories of application of wearable technology are
emerging: 1) with the focus on monitoring motor activities via pedometers or sensor
networks that go beyond the use of simple pedometers; 2) with the emphasis on
medication titration and, more generally, applications in which the severity of
symptoms (e.g. in motor disorders) is assessed and a clinical intervention is adjusted
accordingly; and 3) with the focal point on the assessment of the outcomes of
therapeutic interventions (i.e. physical and occupation therapy) with potential for
gathering information suitable to adjust the intensity and modality of the prescribed
therapeutic exercises. The following three sections summarize recent work by our team
and others in the above-described three areas of development of new applications of
wearable technology in rehabilitation.

2. Monitoring Motor Activities in Patients with COPD

Chronic obstructive pulmonary disease (COPD) is a major public health problem.

COPD is currently the fourth leading cause of death in the world [19], and is projected
to rank fifth in 2020 as a worldwide burden of disease [20]. Disability, hospitalizations,
and medication costs associated with this disease account for 15 billion dollars in lost
revenues and health care expenditures annually, an estimated 16 % of the national
health care budget [21]. Despite the increasing numbers of patients with COPD, there
has been little advancement in the ability of healthcare providers and clinical
researchers to monitor patients with COPD. The forced expiratory volume in 1 s
(FEV1), long thought to be the gold standard, has been shown to correlate poorly with
other measures of disease status and does not predict mortality and resource utilization.
In the research setting, the FEV1 takes too long to change to be an efficient and
meaningful outcome measure. Recent work by our team [22] and others [23, 24] has
focused on the hypothesis that measurement of cumulative free-living physical activity
with wearable technology in the patient’s home environment combined with
physiological data collection (heart rate, respiratory rate, and oxygen saturation) can
complement current clinical assessments of disease status and provide improved
monitoring of COPD patients.
In recent work by our team [22] we studied 6 males and 6 females, mean age 68 +
11 years, with severe COPD. Mean + s.d. FEV1 was 0.96 + 0.51 L (34 + 17%
predicted) and FVC 2.57 + 0.91 L (70 + 18% predicted). At the time of monitoring, the
average six-minute walking distance was 1170 + 304 feet. In Part I of this pilot study,
our aim was to automatically identify three exercises comprising the aerobic portion of
the pulmonary rehabilitation exercise program from a continuous data record: walking
on a treadmill, cycling on a stationary bike, and cycling of the upper extremities on an
arm ergometer. Identification was based on the output of a neural network trained with
examples of accelerometer data corresponding to each of the exercise conditions. We
demonstrated that accurate and reliable identification of the exercise activities could be
achieved, thus enabling monitoring of patients’ compliance with a prescribed exercise
regimen outside of the rehabilitation environment. For misclassification equal to 5%,
the sensitivity of the classifier was remarkably high, ranging from 93 to 98% across
subjects. Details concerning the study are provided in Sherrill et al [25] and Moy et al
[26].
In Part II of this preliminary investigation, we extended the protocol to include
typical activities such as climbing stairs, walking indoors, doing household chores, etc.
Identifying these types of activities is relevant for assessing patients’ overall mobility.
We collected data by providing patients with a script as described in Sherrill et al
[22]. Due to the physical limitations of the COPD individuals, it was not feasible to
gather more than a minute of data for tasks such as ascending stairs. Since the number
of features derived from the accelerometer data far exceeded the number of data
segments available, a neural network approach was not considered to be appropriate.
We envisioned therefore compiling data from a large group of patients and performing
all identifications based on an existing database of examples rather than custom-
training the classifier for each individual. In order for this to be a workable solution, the
variability across tasks must exceed the variability within tasks due to different
individuals. To show that this was a feasible approach, we sought ways to visualize the
relationships among clusters of data points corresponding to the conditions of interest.
We combined principal components analysis (PCA) and Sammon’s mapping. First, a
PCA transformation was applied, and the first 15 PCs (accounting for 90% of the total
variance) were retained. Then, the Sammon’s map was computed on the transformed
data. Results were viewed as a scatter plot, color-coded by task as shown in Figure 5
utilizing a gray scale. A clear division is evident among tasks. Techniques to assess the
“quality” of the clusters were then utilized as reported in Sherrill et al [22], thus
allowing us to conclude that the motor activities of interest can be classified based on
accelerometer data recorded from upper and lower extremities.
 fold laundry arm ergometer

sweep floor climb stairs

treadmill

stationary
bike

walk in hallway

Figure 5. Clustering of features derived from accelerometer data recorded while patients with COPD
performed various motor tasks. Results are plotted for 7 tasks that were performed by the 5 patients who
participated in the study. Each task is represented by 20 randomly selected data points per patient that were
projected in two dimensions using the Sammon’s map algorithm. Each task occupies a distinct subregion of
the data space, forming distinct clusters in each region. Cluster positions are suggested by circles overlaid on
the plots. Axes are the result of abstract transformations on normalized data and therefore units are not shown.

3. Medication Titration in Individuals with Parkinson’s Disease

Parkinson’s disease is the most common cause of movement disorder, affecting about
3% of the population over the age of 65 years and more than 500,000 US residents. The
characteristic motor features of Parkinson’s disease include the development of rest
tremor, bradykinesia (i.e. slowness of movement), rigidity (i.e. resistance to externally
imposed movements), and impairment of postural balance. The primary biochemical
abnormality in Parkinson’s disease is deficiency of dopamine due to degeneration of
neurons in the substantia nigra pars compacta. Current therapy of Parkinson’s disease is
based primarily on augmentation or replacement of dopamine, using the biosynthetic
precursor levodopa or other drugs that activate dopamine receptors [27, 28]. These
therapies are often successful for some time in alleviating the abnormal movements,
but most patients eventually develop motor complications as a result of these
treatments [29, 30]. These complications include wearing off, the abrupt loss of
efficacy at the end of each dosing interval, and dyskinesias, involuntary and sometimes
violent writhing movements. Wearing off and dyskinesias produce substantial
disability, and frequently prevent effective therapy of the disease [31, 33].
Currently available tools for monitoring and managing motor fluctuations are quite
limited [34, 35]. In clinical practice, information about motor fluctuations is usually
obtained by asking patients to recall the number of hours of ON (i.e. when medications
effectively attenuate tremor) and OFF time (i.e. when medications are not effective)
they have experienced in the recent past. Figure 6 shows a schematic representation of
a motor fluctuation cycle (i.e. interval between two medication intakes) and the
occurrence of dyskinesia. Dyskinetic movements are observed at certain points of the
cycle. Patients are asked to report the duration of these symptoms in terms of percent of
awake time spent in each state. This retrospective approach is formalized in Subscale
Four of the Unified Parkinson’s Disease Rating Scale (UPDRS) [36] referred to as
“Complications of Treatment”. This kind of self-report is subject to both perceptual
bias (e.g. patients often have difficulty distinguishing dyskinesia from other symptoms)
and recall bias. Another approach is the use of patient diaries, which does improve
reliability by recording symptoms as they occur, but does not capture many of the
features that are useful in clinical decision-making [37]. In clinical trials of new
therapies, both the diary-based approach [37] as well as extended direct observations of
the patients in a clinical care setting [38] have been used, but both capture only a small
portion of the patient’s daily experience and are burdensome for the subjects.
Based on these considerations, our team [39] and others [40] have developed
methods that rely on wearable technology to monitor longitudinal changes in the
severity of symptoms and motor complications in patients with Parkinson’s disease. In
our own study, we recruited twelve individuals, ranging in age from 46 to 75 years,
with a diagnosis of idiopathic Parkinson’s disease (Hoehn & Yahr stage 2.5 to 3, i.e.
mild to moderate bilateral disease) [36]. Subjects delayed their first medication intake
in the morning so that they could be tested in a “practically-defined OFF” state
(baseline trial). This approach is used clinically to observe patients during their most
severe motor symptoms. Subjects were instructed to perform a series of standardized
motor tasks utilized in clinically evaluating patients with Parkinson’s disease.
Accelerometer sensors positioned on the upper and lower extremities were used to
gather movement data during performance of the standardized series of motor tasks
mentioned above. The study focused on predicting tremor, bradykinesia, and
dyskinesia based on features derived from accelerometer data. Raw accelerometer data
were high-pass filtered with a cutoff frequency of 1 Hz to remove gross changes in the
orientation of body segments [41]. An additional filter with appropriate characteristics
was applied to isolate the frequency components of interest for estimating each
symptom or motor complication. Specifically, the time series were band-pass filtered
with bandwidth 3-8 Hz for the analysis of tremor, and they were low-pass filtered with
a cut-off frequency of 3 Hz for the analysis of bradykinesia and dyskinesia. All the
filters were implemented as IIR filters based on an elliptic design. The accelerometer
time series were segmented using a rectangular window randomly positioned
throughout the recordings performed during performance of each motor task. [42]
Features were extracted from 30 such data segments (i.e. epochs) for each motor task
from the recordings performed from each subject during each trial. Five different types
of features were estimated from accelerometer data recorded from different body
segments. The features were chosen to represent characteristics such as intensity,
modulation, rate, periodicity, and coordination of movement. We implemented Support
Vector Machines to predict clinical scores of the severity of Parkinsonian symptoms
and motor complications. Our results demonstrated that an average prediction error not
exceeding a few percentage points can be achieved in the prediction of Parkinsonian
symptoms and motor complications from wearable sensor data. Specifically, average
prediction error values were 3.5 % for tremor, 5.1 % for bradykinesia, and 1.9 % for
dyskinesia. [43].
 ON WEARING-OFF

Onset Peak-Dose End-of-Dose

Dyskinesia Dyskinesia Dyskinesia
OFF OFF
Levodopa
Intake
Figure 6. Example of the cyclical pattern of motor abnormalities observed in patients with Parkinson’s
disease for dyskinesia during a motor fluctuation cycle.

4. Assessment of Rehabilitation Interventions in Patients Post Stroke

More than 700,000 people are affected by stroke each year in the United States [44].
Strokes affect a person’s cognitive, language, perceptual, sensory, and motor
abilities [45]. More than 1,100,000 Americans have reported difficulties with
functional limitations following stroke [46]. Recovery from stroke is a long process
that continues beyond the hospital stay and into the home setting. The rehabilitation
process is guided by clinical assessments of motor abilities, which are expected to
improve over time in response to rehabilitation interventions. Telerehabilitation has the
potential to facilitate extending therapy and assessment capabilities beyond what can be
achieved in a clinical setting.
Accurate assessment of motor abilities is important in selecting the best therapies
for stroke survivors. These assessments are based on observations of subjects’ motor
behavior using standardized clinical rating scales. Wearable sensors could be used to
provide accurate measures of motor abilities in the home and community settings and
could be leveraged upon to facilitate the implementation of telerehabilitation protocols.
Our team has performed pilot studies exploring the use of wearable sensors
(accelerometers) and an e-textile glove-based system (herein referred to as “data
glove”) designed to monitor movement and facilitate the implementation of physical
therapy based on the use of video games.
We demonstrated that accelerometers can be utilized to predict the Wolf
Functional Ability Score (FAS). The Wolf FAS provides a measure of the subject’s
quality of movement based on an evaluation of the quality of movement during
performance of the Wolf Motor Performance Test [47]. The scores capture factors such
as smoothness, speed, ease of movement, and amplitude of the compensatory
movements. Twenty-three subjects who had a stroke within the previous 2 to 24
months were recruited for the study. Accelerometers were positioned on the sternum
and the affected (i.e. hemiparetic) arm. Subjects performed multiple repetitions of tasks
requiring reaching and prehension, selected from the Wolf Motor Performance Test.
The tasks included reaching to close and distant objects, placing the hand or forearm
from lap to a table, pushing and pulling a weight across a table, drinking from a
beverage can, lifting a pencil, flipping a card, and turning a key. Accelerometer data
were processed to derive features that captured different aspects of the movement
patterns and were fed to a classifier built using a Random Forest. The Random Forest
approach is based on an ensemble of decision trees and is suitable for datasets with low
feature-to-instance ratio. We assessed the reliability of the estimates achieved using this
method by deriving the prediction error for each of the investigated motor tasks. The
estimated prediction error for such motor tasks ranged between about 1 % and 13 %.
This is a very encouraging result as it suggests that FAS scores could be estimated via
monitoring motor tasks performed by patients in the home and community settings
using accelerometers.
Our team also studied the feasibility of utilizing a sensorized glove to implement
physical therapy protocols for motor retraining based on the use of video games. The
glove was utilized to implement grasp and release of objects in the video games. This
function was achieved by defining a measure of “hand aperture” and estimating it
based on processing data gathered from the data glove. Calibration of the data glove
was achieved by asking individuals to hold a wooden cone-shaped object with diameter
ranging from 1 cm to 11.8 cm at different points of the cone corresponding to a known
diameter. The output of the sensors on the glove was used to estimate the diameter of
the section of the cone-shaped object corresponding to the position of the middle finger.
A linear regression model was utilized to estimate the above-defined measure of “hand
aperture” (dependent variable) using the glove sensor outputs as independent variables.
Encouraging results were achieved from the study. The estimation error that marked
the measures of “hand aperture” as defined above was smaller than 1.5 cm. We
consider this result as satisfactory in the context of the application of interest, i.e. the
implementation of video games to train grasp and release functions in individuals post
stroke.
Overall, the results herein summarized indicate that the investigated wearable
technologies are suitable to implement telerehabilitation protocols.

Figure 7. A subject testing the data glove herein described in combination with a robotic system for
rehabilitation.
5. Conclusions

The assessment of the impact of rehabilitation interventions on the daily life of

individuals is essential for developing protocols that maximize the impact of
rehabilitation on the quality of life of individuals. The use of questionnaires is
somehow limited because questionnaires are subject to perceptual bias and recall bias.
Furthermore, relying on questionnaires is bound to introduce a delay in the response to
changes in patient’s status since the information needed to make a clinical decision
concerning changes in rehabilitation interventions is not readily available on a
continuous basis but rather questionnaires are administered sporadically. Wearable
technology has the potential to overcome limitations of existing methodologies to
assess the impact of rehabilitation interventions on the real life of individuals.
Miniature unobtrusive sensors can provide clinicians with quantitative measures of
subjects’ status in the home and community settings thus facilitating making clinical
decisions concerning the adequacy of ongoing interventions and possibly allowing
prompt modification of the rehabilitation strategy if needed. In this chapter, we
presented three applications that point at potential areas of use of wearable technology
in rehabilitation.
In the first example, we showed that wearable sensors can provide clinicians with a
tool to monitor exercise compliance in patients with COPD. We also showed that
activities of daily living that are associated with different systemic responses can be
identified with high reliability. It is conceivable that based on trends identified via
analysis of changes in activity level and systemic responses associated with certain
motor tasks, we could achieve early detection of exacerbation episodes. The impact on
our ability to care for patients with COPD would be paramount.
In the second example, we demonstrated that we can monitor the severity of
symptoms and motor complications in patients with Parkinson’s disease. This is
important in the late stages of the disease when motor fluctuations develop. Since
motor fluctuations span an interval of several hours, observations performed in a
clinical setting (typically limited to the duration of the outpatient visit, i.e. about 20-
25 minutes) are not sufficient to capture the severity of motor fluctuations. Monitoring
patients in the home and community settings could therefore substantially improve the
clinical management of patients with late stage Parkinson’s disease. Our results suggest
that the technique summarized in this chapter could be extended to monitoring patients
with other neurodegenerative conditions that are accompanied by motor symptoms.
Finally, we demonstrated that wearable technology could provide clinicians with a
means to assess functional ability in individuals post stroke. This is important because
we currently have very limited tools to assess the impact of rehabilitation interventions
on the real life of patients. Although it is expected that therapeutic interventions that
are associated with improvements in impairment level and functional level lead to an
improved quality of life, it would be very useful to quantify such impact and compare
different interventions measuring their impact on the performance of activities of daily
living via processing data gathered in the home and community settings. Tools to
monitor patients in the home and community settings could lead to new criteria for
adjusting interventions that maximize the impact on real life conditions of the adopted
therapeutic intervention. We anticipate that such criteria would allow clinicians to help
patients achieving higher level of independence and better quality of life.
All in all, the examples provided in this chapter indicate that wearable technology
has tremendous potential to allow clinicians to improve quality of care thus resulting in
a likely improvement in quality of life in individuals in response to rehabilitation. The
next challenge in wearable technology is indeed to demonstrate that such
methodologies can have a significant impact on the quality of care provided to patients
and their quality of life.

Acknowledgments

The author wishes to thank Dr. Sunderasan Jayaraman, Dr. Alex (Sandy) Pentland, and
Dr. William Tang for allowing him to utilize figures that they utilized in previous
communications and for their input on a draft of this chapter. The work on wireless
technology summarized in this chapter was largely carried out by Dr. Matt Welsh and
his team at the Harvard School of Engineering and Applied Sciences. Applications of
e-textile solutions were pursued jointly with Dr. Danilo De Rossi, University of Pisa,
and his associates Dr. Alessandro Tognetti and Mr. Fabrizio Cutolo. Dr. Rita Paradiso
(Smartex) provided expertise and support in the development of the data glove
discussed in this chapter. The pilot study concerning the application of wearable
technology to monitor patients with COPD was performed with Dr. Marilyn Moy at
Harvard Medical School and Ms. Sherrill Delsey, currently at the MIT Lincoln
Laboratory, who was at Spaulding Rehabilitation Hospital at the time the study
described in this chapter was performed. The development of methodologies to assess
the severity of symptoms and motor complications in patients with Parkinson’s disease
was performed with Dr. John Growdon and Ms. Nancy Huggins at Massachusetts
General Hospital. Algorithms for the analysis of accelerometer data were developed by
Mr. Shyamal Patel, Northeastern University. Mr. Richard Hughes, currently with
Partners HomeCare, who was at Spaulding Rehabilitation Hospital at the time the study
described in this chapter was performed, provided clinical scores for all the patients’
recordings. Mr. Richard Hughes also contributed to the pilot study we performed to
assess the use of wearable technology in patients post stroke. Medical expertise for this
project was provided by Dr. Joel Stein, currently at Columbia University, who was at
Spaulding Rehabilitation Hospital at the time the study was performed. Algorithms for
the analysis of data recorded from patients post stroke were developed by Mr. Todd
Hester, currently at University of Texas Austin, who was at Spaulding Rehabilitation
Hospital at the time the study was performed. Mr. Shyamal Patel, Northeastern
University, also contributed to the development of these algorithms.

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