Robot-Guided Exercise Program for the Rehabilitation of Older Nursing Home Residents
1Department of Management, University of Vaasa, Vaasa, Finland
2Department of Biomedical Engineering, Tampere University of Technology, Tampere, Finland
Abstract: Physical activity has a significant impact on the health of older adults. Socially interactive robots can be used to encourage and guide the performance of rehabilitation exercises designed for elderly people. In this article, the authors present the results of their project, which studied the use of a small humanoid robot to facilitate rehabilitation exercises in three private nursing homes in the Finnish county of South Ostrobothnia. The researchers programmed the robot to lead several exercise regimens, which could be performed by the residents while seated on chairs. During the exercise sessions, the robot demonstrated the hand and leg motions, while providing prerecorded instructions for each motion. The feedback from both the residents and the nursing home staff was mainly positive.
Key words: Rehabilitation, quality of life, robotics, exercise.
The aging population is increasingly placing pressure on an already taxed healthcare system. In assisted living facilities and nursing homes, there are considerable financial challenges and staffing shortages to contend with, yet the growing elderly population is projected to generate an even more severe shortage of caretakers in the near future. To address this concern, various technical concepts, including technologies that incorporate artificial intelligence and telemedicine systems, have been developed.1,2
Because physical activity may delay the onset of physical deficits while contributing to overall improved health in older adults,3 different types of exercise programs have been used for this population. These programs have been implemented in various care settings, including nursing homes, but because they are beneficial only when followed regularly and consistently, adherence is essential to maximize benefits. Due to financial and resource constraints, it is often difficult to arrange regular exercise sessions with a physical therapist and/or a fitness trainer. One way to potentially address this problem is to use robot technology to fill the gaps. In this article, we present the results of our study, which assessed the use of a robot as a means of guiding nursing home residents through an exercise program.
We used an NAO H25 robot manufactured by Aldebaran Robotics in our study (Figure 1). This robot is a programmable, humanoid robot that is approximately 22 inches in height and capable of autonomous movement by using its electric motors and actuators, which enable 25 degrees of freedom. The robot also has a variety of sensors and devices, including cameras, microphones, distance sensors, a voice synthesizer, speakers, and a wireless local area network connection for communication and information transmission.
We assessed the NAO robot as an exercise trainer at three private nursing homes in the Finnish county of South Ostrobothnia. These nursing homes had a small population of residents (≤22 persons). Many of these residents had a limited ability to walk or had some cognitive problems related to memory. Before initiating the robot-guided exercise program, all residents were shown how it worked so that they could decide whether to participate. After watching the demonstration, 34 of the 44 residents (77%) at these homes decided to do the program (Table), and the robot-guided exercise program was tested from November 2011 to May 2012.
During this period, the robot was tested four times in each nursing home. A member of the nursing home staff supervised the testing and was assisted by a member of the research group, whose presence was required to ensure that the robot worked properly. For the testing, the robot was programmed to demonstrate several different exercise routines. These routines were then implemented in a group session with both the robot and the participants sitting in chairs (Figure 2). The robot showed the participants arm and leg motions and provided prerecorded instructions for each motion. The exercise programs typically lasted 10 to 20 minutes and included three to five repetitions of each motion, with three to four different motions for both arms and legs. Different music played during each testing session.
The exercise program was continuously developed during the testing period based on the feedback we received from the residents. This feedback was obtained through informal discussions with the residents at the end of each testing session. To obtain more structured feedback on the robot-guided exercise program, we also designed a written survey for the personnel of the nursing homes. The survey, which was conducted during the final testing day, included the following questions:
(1) What is your opinion of the robot-guided exercise program? How well does it work?
(2) What kind of feedback have you received from the residents regarding the robot-guided exercise program?
(3) What are your suggestions on how to improve the robot-guided exercise program?
(4) What other uses can you identify for the robot in the rehabilitation of the elderly?
After engaging in the program, most residents had positive feedback, although some of the participants were more interested in the robot than the exercise program. The residents also had several ideas on how the program could be improved. Initially, the robot’s hands and legs had no color, but the residents recommended that we add color to them to make them more visible. Another suggestion was to delineate each exercise (eg, arm movements, leg movements) by playing different music, rather than only switching the music for each testing session. We made these changes, and they were well received at sub-sequent testing sessions.
Of the staff surveys, we received responses from all of the staff members from the three nursing homes who were present during the testing sessions (N=13). With regard to the first question, the general consensus was that a robot-guided exercise program is well suited for the elderly, especially more active persons, as these individuals are the most likely candidates to participate in a variety of exercises and activities in the nursing home. They also noted that more passive residents do not always follow along with the exercises without support from staff; thus, for such individuals, exercises led by a human might be more appropriate. In addition, because the robot is relatively small, the staff stated that it must be located on a table close to the participants during the sessions so that everyone can see it clearly.
Regarding the second survey question, the staff indicated that resident feedback was mainly positive. They noted that several residents were curious about the robot and expressed an interest in the robot-guided exercises. They also stated that many residents spoke about the robot afterwards and asked a variety of questions about it.
With regard to the third question, most suggestions for improvement were related to the speed of the robot’s motions, volume of speech and music, and visibility of the robot’s hands, arms, and legs. The staff noted the importance of the motions of the robot being slow enough for residents to follow along and the speech being clear and loud so that they could understand the prompts. They noted that some residents had difficulty seeing the robot’s hand and arm movements because of the robot’s small size, but once we added color to the robot’s extremities, this improved.
Regarding the third survey question, several other uses for the robot were suggested. One suggestion was to use the robot to entertain the residents, such as functioning as an interactive music player. Another recommendation was to program the robot to provide cognitive exercises, such as question and answer sessions, but that such exercise sessions should be no longer than 8 to 10 minutes because of residents’ limited ability to maintain concentration for long periods of time.
Our study has several limitations. First, our study population was small, as we tested the robot in small nursing homes, which provided a more intimate, home-like environment; thus, whether the robot would be feasible in a larger, more institutional nursing home setting is unclear. Second, the robot itself was small, which limited the types of exercises we could program into the robot; for example, finger manipulation exercises would be difficult for the robot to demonstrate, particularly in a group setting. Third, we did not evaluate the robot’s impact on the physical health and well being of residents, so it is not clear whether a robot can serve as a suitable substitute to a physical therapist and/or a fitness trainer with regard to leading exercise sessions that do not require monitoring by such professionals.
Our current study was not the first time we used an NAO robot in the nursing home setting. Previously, we successfully used this robot as part of a remote monitoring system that was developed for nursing homes.4 The robot received alarms that were either automatic or activated by the residents via its wireless Internet connection and navigated independently to the room where the alarm originated. After it entered the room, the robot transmitted near–real-time images to the staff and opened a voice connection between the resident and the remote caregiver(s). This enabled the remote caregiver(s) to check on the patient and take appropriate action if intervention was required. The nursing home residents and staff responded positively to this remote monitoring system.4
Because physical activity is essential for elderly nursing home residents, particularly those who are sedentary, we decided to evaluate the NAO robot as an exercise trainer. Conventional rehabilitation generally involves one-on-one interaction with a physical therapist and/or fitness trainer, both of who assist and encourage the patient through repetitive exercises5; however, one-on-one rehabilitation is not always an option due to factors such as financial limitations. In these situations, interactive robotic therapists can provide reproducible exercise programs (ie, exercise activities that residents can perform without the supervising presence of a therapist), and these robotic therapists can be programmed to carry out a number of exercise programs of different levels and requirements. These programs can be individually tailored based on patients’ physical and cognitive abilities. Because different programs can be preprogrammed into the robot’s memory, there would be no need for special staff to take care of the robot. In addition, the same robot could be used for multiple purposes, such as for monitoring activities and as an exercise trainer.
Currently, there are two basic types of robots that can be used in healthcare settings: assistive robots and socially interactive robots.6 Assistive robots provide assistance to the user, such as by performing a physical task that the patient or caregiver is unable to perform. When we used the NAO robot as a part of a remote monitoring system, it functioned as an assistive robot, alleviating the staff burden of having to physically check on every alarm. Socially interactive robots communicate with the user through social and nonphysical interaction. We used the NAO robot in this manner for the robot-guided exercise programs, as it led residents through an exercise program and provided them with prompts to facilitate interactivity. In most cases, assistive robots capable of physical interaction are the best choice for facilitating geriatric care.
In the nursing home, robots have been used for a variety of purposes. For instance, they have been used to support nursing home staff with the residents’ daily activities7; typical examples of the tasks carried out by robots include improving drug compliance,8 increasing physical exercise adherence,9 playing the role of a companion animal,10 or assisting in different kinds of rehabilitation tasks, such as those targeted to stroke survivors.5 Additionally, Cesta and colleagues11 described a monitoring approach in which a robot worked as part of an intelligent home environment as a means of enabling elderly persons to age in place.
Although the ultimate goal of robotics may be to develop humanoid robots that independently perform a vast gamut of functions, rather than single tasks, robotics is still in its infancy. Currently, humanoid robots are clumsy and expensive, making them a poor substitute for human caretakers. To address this problem, Japan, which has a growing elderly population and a critical shortage of caretakers, launched a “Home-use Robot Practical Application Project” in 2009, after it had spent billions of yen focused on humanoid robotics research.12,13 Through this project, the Japanese government has increased its focus on commercializing simple robots that perform single, focused tasks as a means of enabling more elderly persons to age in place. In addition, the Japanese government has announced that starting in 2013, it is providing subsidies to firms working on nursing care robots.12 These subsidies are projected to cover 50% to 66% of research and development costs. Four specific types of assistive nursing care robots are included in this plan: (1) a motorized robot suit that can facilitate caretakers lifting and moving physically impaired patients; (2) an ambulatory robot that enables elderly persons and others with impaired mobility to walk by themselves, including on inclines; (3) a monitoring robot that can track the movement of dementia patients and indicate their location; and (4) a portable, self-cleaning robot toilet that can facilitate toileting activities.12 The government’s goal is to alleviate the chronic shortage of nursing care workers by promoting a variety of low-cost nursing care robots.
The humanoid robot we used in our research was not specifically designed to be an exercise trainer or a remote monitoring system, but was successfully programmed to carry out these functions. Our findings indicate that until humanoid robots become more sophisticated, the current generation of humanoid robots can still serve important functions in the nursing home setting; however, at a cost of approximately $16,000 each, these robots could remain cost prohibitive for some facilities. Nevertheless, as robotics technology continues to advance, it will become increasingly more affordable. We also speculate that once humanoid robots become affordable and capable of performing a vast variety of tasks independently, there will still be a need for a wide variety of simple, single-function robots.
The feedback we received regarding use of the NAO robot as an exercise trainer has been mainly positive, indicating that use of a humanoid robot for the rehabilitation of elderly nursing home residents is feasible and warrants further investigation. One important component of future research is to examine the long-term health outcomes of nursing home residents who engage in robot-guided exercise programs versus those who undergo such programs with human therapists. In addition, use of the robot to engage residents in other social activities should be explored, as the exercise activities we programmed into our NAO robot serve as only one example of how these robots can be used to socially interact with and engage residents. With all of the enablers required for independent movement and interaction with people, the NAO robot could be used to guide residents through a wide variety of mentally and physically stimulating activities, opening up new areas of development and research.
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Disclosures: The authors report no relevant financial relationships.
Address correspondence to: Iivari Bäck, PhD, University of Vaasa, Department of Management
P.O. Box 700, FI-65101 Vaasa, Finland; Iivari.firstname.lastname@example.org