Ref. Ares(2015)4919513 - 07/11/2015
I-SUPPORT
HORIZON 2020 PHC-19 Research & Innovation Actions Grant agreement n°: 643666
I-Support: ICT-Supported Bath Robots
Deliverable Title: I-Support Models of user abilities and behaviour, use cases and system functionalities
Responsible Partner: FRA-UAS
Research & Innovation Actions
Horizon 2020 ICT-Supported Bath Robots
RIA Project: I-SUPPORT Full title: ICT-Supported Bath Robots Project start date: 1 st March 2015 Duration of the 3 years project: Coordinator: ROBOTNIK Technical ICCS Coordinator: Project Partners: ICCS, INRIA, KIT, SSSA, OMEGA-TECHNOLOGIES, FSL, FRA-UAS, BETHANIEN, ROBOTNIK Project URL : http://www.i-support-project.eu EU Project Jan KOMAREK Officer:
I-Support Models of user abilities and Report/Deliverable N R/D1.1 Title behaviour, use cases and system functionalities
User Requirements, system functionalities, Work package N WP 1 Title safety and ethics
Frankfurt University of Applied Science (FRA-UAS) Responsible Partner Barbara Klein Email [email protected]
Barbara Klein, Sarah-Sabrina Kortekamp, Holger Roßberg (FRA-UAS), Responsible Klaus Hauer, Jochen Werle (Bethanien), Costas Tzafestas, Xanthi Authors Papageorgiou, Nancy Zlatintsi (ICCS), Angelo Sabatini, Vincenzo Genovese (SSSA), Panagiotis Vartholomeos (Omega)
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 2 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
In order to develop use cases and system functionalities a Abstract (for comprehensive approach was chosen comprising a clinical and a dissemination) sociological perspective: The first two chapters are from a clinical point of view. Based on literature analysis user definition for the I-SUPPORT robot system is provided. Here the inclusion criteria for the acquisition of participants for the validation studies are defined. The two inclusion criteria are 1) a dependency of the possible user regarding bathing tasks, and 2) a MMSE score of 18 or above. The health status of the targeted user group of primary users is then described from a clinical perspective by means of the International classification of Functioning, Disability and health (ICF). Further, the findings are transitioned to potential use cases. The third chapter is based on qualitative research in the framework of the Design Thinking Method which aims on shortening the product development process and the integration of user and stakeholder requirements. 30 interviews with primary users (e.g. frail, elderly persons) and 15 interviews with secondary users (formal and informal carers, healthcare professionals) were conducted in order to analyse the showering process, user abilities and needs and obtain a first feedback on I-SUPPORT ideas and materials. The findings of this study were mostly congruent with the developed use cases, but also added new perspectives. In the fourth chapter the final use cases (i.e. those use cases analysing the I-SUPPORT operations that will be executed during the pilot studies) are described in detail and technical requirements for the I-SUPPORT bath robot system are derived.
Revision procedure
Version # Implemented by Revision date Changes
0.1 Barbara Klein 29/10/2015 Draft version
0.2 Jochen Werle, 30/10/2015 First comments and corrections Klaus Hauer
0.3 Holger Roßberg 31/10/2015 First corrections, suggestions
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 3 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
0.4 Jochen Werle 01/11.2015 Second comments and corrections
0.5 Holger Roßberg 01/11/2015 Second corrections, suggestions
0.6 Jochen Werle 04/11/2015 Last comments and corrections
0.7 Holger Roßberg 06/11/2015 Final corrections
0.8 Barbara Klein 06/11/2015 Final version
Approval procedure Partners involved: the consortium
Version # Report/Deliverable Approved by Approval date
1.0 D1.1 Panagiotis Vartholomeos 04/11/2015
Electronic filing procedure
Document Name and I-Support Models of user abilities and behaviour, use cases and version system functionalities, V1.0
Location http://www.i-support-project.eu/internalworkspace/
Filing date 04/11/2015
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 4 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table of Contents
TABLE OF CONTENTS 5
1 I-SUPPORT USER DEFINITION 8 1.1 INTRODUCTION 8 1.2 DECLINE IN ADL-FUNCTION / BATHING 9 1.3 ASSESSMENT STRATEGIES 13 1.3.1 BATHING LIMITATIONS 13 1.3.2 COGNITIVE STATUS 14 1.3.3 FLOW CHART OF THE DEFINITION PROCESS 15 1.4 SUMMARY 16
REFERENCES 18
APPENDIX: CLINICAL ASSESSMENTS 20
2 MODELLING USER REQUIREMENTS AND ASSOCIATED USE CASE SCENARIOS - THE CLINICAL PERSPECTIVE 29
2.1 INTRODUCTION 29 2.2 INTERNATIONAL CLASSIFICATION OF FUNCTIONING, DISABILITY AND HEALTH (ICF) AS FRAMEWORK FOR MODELING USER REQUIREMENTS 30 2.2.1 ASSESSMENT OF FUNCTIONS AND DISABILITIES – ICF CORE SETS 34 2.3 DESCRIPTION OF FREQUENT GERIATRIC IMPAIRMENTS 35 2.3.1 MENTAL FUNCTIONS (B1) 37 2.3.1.1 ORIENTATION FUNCTIONS (B114) 38 2.3.1.2 ATTENTION FUNCTIONS (B140) 38 2.3.1.3 MEMORY FUNCTIONS (B144) 38 2.3.1.4 BASIC AND HIGHER-LEVEL COGNITIV FUNCTIONS (B163, B164) 39 2.3.1.5 EMOIONAL FUNCTIONS (B152) 39 2.3.1.6 CONSEQUENCES FOR BATHING/SHOWERING ACTIVITIES 40 2.3.2 NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS (B7) 41 2.3.2.1 MOBILITY OF JOINT AND BONE FUNCTIONS (B710, B720) 41 2.3.2.2 MUSCLE POWER FUNCTIONS (B730) 41 2.3.2.3 INVOLUNTARY MOVEMENT REACTION FUNCTIONS (B755) 42 2.3.2.4 CONTROL OF VOLUNTARY FUNCTIONS (B760) 42 2.3.2.5 GAITH PATTERN FUNCTIONS (B770) 42 2.3.2.6 CONSEQUENCES FOR BATHING/SHOWERING ACTIVITIES 43 2.3.3 SENSORY FUNCTIONS AND PAIN (B2) 44 2.3.3.1 SEEING FUNCTIONS (B210) 44
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 5 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
2.3.3.2 HEARING FUNCTIONS (B230) 45 2.3.3.3 VESTIBULAR FUNCTIONS (B235) 45 2.3.3.4 SENSATIONS ASSOCIATED WITH HEARING AND VESTIBULAR FUNCTION (B240) 45 2.3.3.5 PROPRIOCEPTIVE FUNCTIONS (B260) 46 2.3.3.6 SENSORY FUNCTIONS RELATED TO TEMPERATURE AND OTHER STIMULI (B270) 46 2.3.3.7 SENSATION OF PAIN (B280) 47 2.3.3.8 CONSEQUENCES FOR BATHING/SHOWERING 47 2.3.4 FUNCTIONS OF THE SKIN AND RELATED STRUCTURES (B8) 48 2.3.4.1 PROTECTIVE FUNCTIONS OF THE SKIN (B810) 48 2.3.4.2 CONSEQUENCES FOR BATHING/SHOWERING 48 2.3.5 URINATION AND DEFECATION FUNCTIONS (B620, B525) 48 2.3.5.1 URINARY CONTINENCE (B6202) 49 2.3.5.2 FECAL CONTINENCE (B5263) 49 2.3.5.3 CONSEQUENCES FOR BATHING/SHOWERING 49 2.4 MODELING OF USER REQUIREMENTS AND USE CASE SCENARIOS 50 2.5 SUMMARY 58
REFERENCES 59
3 USER ABILITIES AND NEEDS 69 3.1 INTRODUCTION 69 3.2 METHOD 69 3.2.1 DESIGN THINKING METHOD 69 3.2.2 METHODS APPLIED FOR THE USER REQUIREMENT ANALYSIS 70 3.2.3 OUTLOOK 71 3.2.4 WORDING AND DEFINITIONS 72 3.2.5 PARTICIPANTS 74 3.2.6 INTERVIEW GUIDELINES 75 3.2.7 INTERVIEWING PROCESS 75 3.3 RESULTS 78 3.3.1 PRIMARY USERS’ HEALTH AND PROBLEMS 78 3.3.2 USERS’ SHOWERING HABITS AND SITUATION/EQUIPMENT 81 3.3.3 RELIGIOUS AND CULTURAL DIFFERENCES REGARDING THE SHOWERING PROCESS 86 3.3.4 OPINIONS ON THE I-SUPPORT CONCEPT, FIRST IMPRESSIONS, AND MATERIALS 87 3.3.5 ACCEPTANCE 94 3.4 DISCUSSION 96 3.4.1 DERIVED USER REQUIREMENTS 96 3.4.2 SPECIAL CONCERNS 98
REFERENCES 99
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 6 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
APPENDIX 100
4 USE CASES AND SYSTEM FUNCTIONALITIES 150
4.1 INTRODUCTION (BETHANIEN) 150 4.2 INITIAL USE CASE SCENARIOS AND USE CASES (BETHANIEN) 151 4.3 FINAL USE CASES AND TECHNICAL IMPLEMENTATION (OMEGA, ICCS, SSSA) 166 4.3.1 METHODOLOGY (OMEGA) 166 4.3.2 USE CASES, ASSOCIATED FUNCTIONALITIES AND TECHNICAL REQUIREMENTS (OMEGA, ICCS, SSSA) 167 4.3.2.1 USE CASE SCENARIO - STAND-TO-SIT, TRANSITION AND SIT-TO-STAND TRANSFER (OMEGA) 168 4.3.2.2 USE CASE SCENARIO - BACK REGION PROGRAM (OMEGA) 171 4.3.2.3 USE CASE SCENARIO - DISTAL REGION PROGRAM (OMEGA) 176 4.3.2.4 USE CASE SCENARIO - POSTERIOR REGION PROGRAM (OMEGA) 182 4.3.2.5 USE CASE SCENARIO - OPERATION, CONTROL AND MODIFICATION OF SYSTEMS FUNCTIONALITIES (ICCS, SSSA) 186 4.3.3 TREE DIAGRAM OF FUNCTIONALITIES AND TECHNICAL REQUIREMENTS (OMEGA) 192 4.4 SUMMARY (BETHANIEN) 193
5 SUMMARY OF REPORT 194
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 7 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
1 I-SUPPORT User Definition Authors: Dr. Jochen Werle, Prof. Dr. Klaus Hauer (Bethanien)
1.1 Introduction A special focus of AAL-projects such as I-Support is given to ADL (Activity of Daily Living) abilities, as those define the level of independence and are highly associated to quality of life. It is functional impairments along with cognitive impairments that trigger loss of autonomy and, by admission to nursing homes or private care, also enormous public health costs. The loss of function typically begins with those activities, which are most complex and least basic. Shower and bathing represent most complex ADL, and thus are among the first to be lost within the ageing process and the last to be regained after acute trauma or medical interventions such as surgery. In this chapter we describe the hierarchy of ADL losses within the ageing/disablement process with focus of the target of the I-Support project to support bathing/showering activities. We then describe established assessment strategies for major criteria of the I-Support user definition addressing the functional as well as the cognitive status and give a brief outlook for related steps within the project. For the development of AAL devices as targeted in the I-Support project a clear user definition is necessary. In a preliminary agreement, the I-Support project group decided to focus on home dwelling older persons with beginning ADL deficiencies as primary users. This group is still able to live independently, but is at high risk for adverse events, e.g. falls, and loss of autonomy. They experience mild or moderate functional disabilities and increasing difficulty to perform ADLs, notably bathing/showering activities. Within the disablement process associated to ageing, impairments are highly correlated to each other. In consequence the target group with advanced motor impairment will also show high prevalence of cognitive impairment (Njegovan et al. 2001). Both motor and cognitive impairment represent high-impact predictors of nursing home admission with high risk of losing their autonomy (Guralnik et al. 1994; Gill et al. 2006a) and those impairments will drive the technical development of the projected assistant robot and represent major defining criteria. The definition of user groups will not focus on setting (e.g. institutionalized vs. non institutionalized persons), disease-related definitions, or mere age, as those criteria will not directly define user needs and with respect to functionalities of the I-Support bath robot system. The I-Support user definition will be based on internationally established, valid and reliable clinical assessment strategies with focus on ADL deficits and cognitive impairment with established cut-off values available for the staging of impairment levels.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 8 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
1.2 Decline in ADL-Function / Bathing Activities of daily living (ADLs) is a term used in healthcare to refer to people's daily self-care activities. The concept of ADLs was originally proposed in the 1950s by Dr. Sidney Katz and his team at the Benjamin Rose Hospital in Cleveland, Ohio. Basic ADLs consist of self-care tasks, including Functional mobility (ability to walk, get in and out of bed, and get into and out of a chair); Bathing and showering (washing the body)1, Dressing, Self-feeding (not including cooking), Personal hygiene and grooming (including brushing/combing/styling hair), Toilet hygiene (getting to the toilet, cleaning oneself, and getting back up). The concept of basic ADLs was extended to more complex activities (Instrumental Activities of daily Living, IADLs), which basically require a higher level of planning and executive functions partly also a higher motor-functional performance. IADLs are not necessary for fundamental functioning, but they let an individual live independently in a community, including Housework, Preparing meals, Taking medications as prescribed, Managing money, Shopping for groceries or clothing, Use of telephone or other form of communication, Transportation within the community. The Katz scale of basic ADL has been increasingly used in a variety of situations. Originally, Katz et al. (1963) predicted that people with hip fracture or stroke would regain function with rehabilitation according to a predictable hierarchy (Katz & Akpom 1976). Later, ADLs began to be used to measure disability in populations regardless of diagnosis, and even to determine staffing and reimbursement for health care facilities (Lazaridis et al. 1994). The underlying assumption of the Katz scale is that persons regain abilities and become disabled in a structured sequence based on the “biological primacy of functions" (Jette et al. 1990).
1 The ADL item „bathing“ includes the use of a bath tub or a shower as well as taking a complete sponge bath. In the literature there is no differentiation between bathing and showering activities. Therefore, for the user definition of the I-Support project we decided to use the comprehensive ADL item “bathing”.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 9 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Health professionals often use a person's ability or inability to perform ADLs as a measurement of their functional status, particularly in regard to people with disabilities and the elderly (Katz & Akpom 1976). In community-living older persons aged 65 years and older, the prevalence of bathing disability, defined as help of another person, ranges from 4.6% to 6.9% (Wiener et al. 1990). In a community- dwelling population of 5151 persons aged 70 years and older 12.7% reported bathing difficulties (Lazaridis et al. 1994). 21% of community-living persons aged 85 and older received help performing bathing (Dawson et al. 1987). Among institutionalized elderly population over 90% of residents received help with bathing (Wiener et al. 1990). The prevalence of bathing disability is slightly higher in women than men and increases substantially with age and frailty (Wiener et al. 1990). Gill et al. (2006b) analyzed data of a prospective cohort study with 754 community-living older persons aged 70 years and older and published incidence rates of bathing disability. Over the course of 6 years 58,4% of the participants (N = 440) had at least one episode of bathing disability, and 34,0% (N = 266) had multiple episodes, with the duration of each episode averaging about 6 months (Gill et al. 2006b). The burden of bathing disability was greatest in participants who were physical frail and was consistently higher in women than men and in participants who were aged 80 years and older. Most episodes of bathing disability (86,1%) were not preceded in the prior month by disability in dressing, transferring, or walking, and nearly half (48,3%) were not accompanied at onset by disability in one more of these other ADLs (Gill et al. 2006b). The occurrence of bathing disability is strongly associated with the risk of long-term nursing home admission (Gill et al. 2006a) and the receipt of home care services (LaPlante et al. 2002). Several studies have assessed the extent to which loss of function across ADLs progresses hierarchically. The hierarchy within ADLs was first identified in studies of illness in the aged by Katz et al. (1963). The Index of ADL was developed based on observations of a large number of activities performed by a group of patients (N = 1001) with fracture of the hip. Katz et al. (1963) developed a hierarchy for the observed functions: bathing, dressing, toileting (going to the toilet), transferring, maintaining continence, and feeding. Bathing represents the first ADL to be lost and the first function requiring assistance. When ADL performances got lost by acute trauma or as effect of chronic illness or ageing, the hierarchy of ADL complexity works also the other way round. Recovery of independence in dressing and bathing is the last step of rehabilitation when more basic ADLs have been achieved such as transfers or toileting (after the recovery of independence of transferring and the return of independence of feeding and maintaining continence). This order of recovery of functions in disabled patients is remarkably similar to the order of development of primary functions during early childhood (Katz et al. 1963). This parallelism suggests that the Index of ADL is based on primary biological and psychosocial function, reflecting the adequacy of organized neurological and locomotor response (Katz et al. 1963). Functions that were most essential for survival and least complex (such as feeding) were acquired first and retained longest, while those that were most complex and least basic to survival (for example bathing) were acquired later and lost sooner (Katz et al. 1963; Katz et al. 1970; Katz & Akpom
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 10 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
1976). In the following years a number of cross-sectional studies have evaluated and confirmed the Katz hierarchy (Siu et al. 1990; Travis & McAuley 1990). In a more recent study Gerrard (2013) analyzed data from the 2004 National Nursing Home Survey, a cross-sectional data set of 13.507 skilled nursing facility subjects with functional independence items. A total of 13.113 patients were included in this analysis, the majority of them were female and white. They had an average age of 81 years. The hierarchy found in this population matches the original hierarchy found in older adults in the community, in acute care settings and in the inpatient rehabilitation setting (Gerrard 2013). Lazaridis et al. (1994) examined data from the baseline year of the Longitudinal Study of Aging (LSOA). The LSOA is a prospective survey of 5151 community-dwelling persons aged 70 years and older who were initially interviewed in the 1984 National Health Interview Survey, Supplement on Aging and re-interviewed in 1986. Of the six functional disabilities used by the Katz hierarchy, all but continence were directly measured, via self-report. Continence information was constructed from two questions dealing with bowel and bladder incontinence; an individual answering in the affirmative to either of these questions is considered incontinent. Table 1-1. Number and percentage of persons with each specific disability (Lazaridis et al. 1994). ADL Symbol ADL Description N Percentage Bath Difficulty bathing 625 12,7 Continence Difficulty in continence 603 12,3 Bed Difficulty transferring from bed 485 9,9 Dress Difficulty Dressing 366 7,4 Toilet Difficulty going to toilet 292 5,9 Eat Difficulty feeding 98 2,0 Persons may be counted in more than one category.
This methodological issue might be the reason for the high prevalence of difficulty in incontinence. Several studies suggest continence may not be scalable with the other ADLs (Katz et al. 1963; Lazaridis et al. 1994). Dunlop et al. (1997) referred to data from the Longitudinal Study of Aging (LSOA) too. 2425 Participants were re-interviewed in 1986, 1988, and 1990. The main result of this longitudinal study is to define the onset of disability.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 11 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 1-2. Age in Years of Onset of Disability in ADL and incidence rates: Longitudinal Study of Aging, 1984 through 1990 (Dunlop et al. 1997). Functions Median age in years of onset of disability Total Incidence of disability in %1 Total sample Women Men Women Men (N = 5092) (N = 1837) (N = 3255) Walking 83.9 83.7 85.1 38.2 33.5 Bathing 86.9 86.3 87.9 29.9 25.0 Transferring 89.7 89.4 91.9 23.0 18.8 Dressing 91.8 91.7 92.7 14.1 12.7 Toileting 92.7 91.0 96.2 11.5 9.1 Feeding 99.6 99.6 102.3 8.2 6.3 1 Change in disability over six years (1984 to 1990) among elderly without baseline (1984) disabilities in activities of daily living (n = 2777)
The median age of onset of disability is consistently older for men than for women across all six activities, e.g. for bathing disability 86,3 years for women and 87,9 years for men. It is evident that women consistently experienced higher disability incidence rates than men for all six activities. For example, over the 6-year period, the incidence rate for bathing disability is 29,9% for women and 25,0% for men. The higher incidence rate, compared to other cross-sectional studies is due to methodological issues. In the LSOA study, disability for a specific activity was defined as having difficulty performing that function. Other studies have used different definitions of disability, such as inability to perform an ADL or requiring assistance in order to perform an ADL. The earlier onset of disability in transferring has important implications for the understanding of the natural history of the progression of disability (Dunlop et al. 1997). Transferring requires both upper- and lower-extremity strength and mobility. The fact that both sets of muscles/limbs can be involved may explain transferring's comparative vulnerability to deterioration over time. In contrast to transferring, bathing and dressing may require only upper-extremity flexibility/dexterity in addition to cognitive functioning. This reordering of incident disability based on longitudinal data may indicate that lower-extremity disability precedes upper- extremity disability in a majority of older people in addition to cognitive functioning (Dunlop et al. 1997). Njegovan et al. (2001) studied the hierarchy of functional loss associated with cognitive decline in older persons (N = 5874 community-dwelling persons aged 65 years and older from the Canadian Study of Health and Aging I and II). This is the first prospective study using a large representative cohort of elderly persons to demonstrate that progressive cognitive decline is associated with a specific pattern of loss of functional tasks. In the Canadian Study of Health and Aging the cognitive status was assessed with the Modified Mini-Mental State Examination (3MS). The 3MS cognitive screen was derived from the Mini-Mental State Examination (MMSE). The 3MS screen includes four additional items and a score up to 100 points, which improves its ability to discriminate between those with and without dementia.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 12 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
For example, for persons with incidential loss of bathing ability the median 3MS score is 80, compared to dressing with a score of approximately 68. Overall, those persons who showed a cognitive decline during a 5 year period had significantly larger decline in functional status compared to those who did not show cognitive decline (Teng et al. 1987). The order of loss of independence in ADLs confirms the results of former studies. The order of loss of independence in ADLs, from the least to the most impaired cognitive status, was bathing, walking, toileting, transferring, dressing, grooming, and eating. Again on the basis of cognitive status, the order of loss of independence in IADLs was homemaking, shopping, the ability to use transportation, meal preparation, telephone use, finances, and medication use. Overall, regarding ADLs and IADLs the order of loss of independence was homemaking, shopping, bathing, walking, transportation, meal preparation etc. There was a tendency for dependency for IADL to occur at higher cognitive scores compared with ADLs with an overlap (Njegovan et al. 2001). Bathing as basic ADL is comparable to more complex IADL, e.g. Shopping, Transportation or Meal Preparation. For the I-Support project this is a remarkable result. Bathing, especially with an ICT-supported bath robot system, is as complex as other IADLs with a high impact of cognitive functions. In future times, ICT-supported bathing may be part of the IADL.
1.3 Assessment strategies The I-Support user definition will be based on internationally established, valid and reliable clinical assessment strategies with focus on ADL deficits and cognitive impairment with established cut-off values available for the staging of impairment levels. 1.3.1 Bathing limitations Dependency in the comprehensive bathing activities represents the first inclusion criterion for the definition of the I-Support user group. Bathing is a basic ADL (BADL), used in all functional assessments (e.g. Katz et al. 1963; Mahoney & Barthel 1965; Katz et al. 1970; Katz & Akpom 1976). The Barthel Index (Mahoney & Barthel 1965) is most common and used worldwide for classification of impairment levels in ADL and has high predictive validity for loss of autonomy (Kelly-Hayes et al. 1992; Guralnik et al. 1994; Sonn 1996; Gill et al. 2006a). It is an ordinal scale used to measure performance in BADL. Each performance item is rated on this scale with a given number of scores assigned to each level or ranking. It uses ten variables describing BADLs including mobility and continence items. The Barthel Index is widely used in different settings such as in-patient rehabilitation, home care, nursing care, skilled nursing, and community. It has demonstrated high inter-rater reliability (Intra- class correlation coefficient ICC = 0.95-0.97) and test–retest reliability (ICC = 0.89) as well as good validity documented by high correlations (Spearman´s Rho = 0.74–0.8) with other measures of physical disability (Sainsbury et al. 2005; O´Sullivan & Schmitz 2007).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 13 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
According to the Index of ADL (Katz et al. 1963) we use the Barthel definition of scoring for the item “bathing” to give a clear dichotomous decision between “independent” and “dependent”. The BADL item “bathing” of the Barthel Index will be used as a clear defining criterion for the user group in the I-Support project. Independent: Patient may use a bath tub, a shower, or take a complete sponge bath. He must be able to do all the steps involved in whichever method is employed without another person being present. Dependent: Patient may use a bath tub, a shower, or take a complete sponge bath only with help of another person. 1.3.2 Cognitive Status For screening of cognitive functions we choose the Mini Mental State Examination (MMSE) (Folstein et al. 1975) an internationally well-established screening test for cognitive impairment to classify the cognitive status and allow comparability to other studies also including cognitive criteria. The test has proven high validity, reliability, feasibility to be used as a screening instrument (Folstein et al. 1975, Tombaugh & McIntyre 1992). The time to administer is about 10-15 minutes requesting only limited personal resources for assessment. For a screening tool, the MMSE allows a rather comprehensive documentation of cognitive sub-performances including memory (early- late recall, working memory), executive- and semantic performances, orientation in time and locus. For screening purpose we will not use comprehensive neuro-psychological assessment or a dementia diagnosis because of the high test burden for participants and the high personal and financial resources necessary for a detailed diagnosis of disease. In case the development of the I- Support platform will request further specifications, clinical partners will be able to provide additionally cognitive performance tests (e.g. test for executive function, attention control) as established in specific neuro-psychological assessment. Table 1-3. MMSE – Categories and impairment levels Categories Impairment level I-Support – Inclusion criterion
1 No cognitive impairment (MMSE 24-30) Yes
2 Moderate cognitive impairment (MMSE 18-23) Yes
3 Severe cognitive impairment (MMSE <18) No
For the I-Support user definition we will use established cut-offs (Folstein et al. 1975) with 24-30 scores to define persons without cognitive impairment and scores ranging from 18-23 to define persons with mild to moderate impairment. The patients as described by category 1 and 2 will represent the majority of patients admitted to geriatric rehab or nursing homes.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 14 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
As we start with the development of a new clinical robot we suggest not to include persons with advanced or severe cognitive impairment levels (MMSE <18), as those will be overtaxed to manage the assistance by I-Support bath robot or may need a far more complex handling support. 1.3.3 Flow chart of the definition process The following flow chart summarizes the process of user definition. For the I-Support project we include people with a dependency in bathing and showering activities. Within this group persons with severe cognitive impairments are excluded.
Figure 1-1. Flow Chart I-Support User definition.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 15 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Inclusion criteria – Summary: The ADL item “bathing” gives a dichotomous decision between “independent” and “dependent” and will be used as a clear defining criterion for the main functionality of the I-Support project (support in shower activities). The MMSE-Score allows to classify the cognitive status. Category 1 “No cognitive impairment” (MMSE 24-30) and category 2 “Moderate cognitive impairment” (MMSE 18-23) will be included. They represent the majority of patients admitted to geriatric care or nursing homes. Persons with advanced impairment levels (Category 3; MMSE <18) will be overtaxed to manage the assistance by I-Support bath robot or may need a far more complex handling support.
Table 1-4. I-Support – Inclusion criteria. Function Barthel ADL Index
Bathing dependent
Cognition Mini Mental State Examination MMSE-Score
No impairments 24 - 30
Moderate impairment 18 - 23
1.4 Summary The suggested user definition is purposefully restricted to only two major clinical criteria which relate directly: 1. to the target function of the I-Support device (shower function) and 2. to cognitive status as a main defining criteria for instrumental handling of the shower robot. Such a clear definition will also be helpful for the upcoming validation studies as clear inclusion criteriia for participation. In a further step we will describe a more comprehensive model of user requirements which integrates epidemiological data, specific motor impairments, a decline in sensor functions (e.g. visual-, sensor-, vestibular impairment) and cognitive functions (e.g. executive functions, orientation, planning) or aspects of mental disorders, e.g. fear of falling relevant for shower activities in old age. The user definition may therefore be amended by additional criteria for specific purposes of the technical development and the upcoming validation studies. Such optional additional criteria will
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 16 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
focus on functional and cognitive impairments of the user group relevant for both shower activities and specific technical functionalities as targeted in the I-Support project. Clinical partners will provide adequate and established clinical assessment strategies for additional criteria. Such a comprehensive user definition/description will be completed by identification of user behaviors and needs from a qualitative perspective as identified by qualitative interviews and quantitative data collection (FH-Frankfurt). Use case scenarios will then be defined to develop and test future functionalities of the I-Support project. Use cases will be based on the user definitions and comprehensive user models as described above. Clinical knowledge, results of extensive user interviewing and technical abilities of project partners will then be merged into project functionalities to achieve project goals as stated in the project proposal.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 17 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
References Dawson, D. Hendershot, G. & Fulton, J. (1987). Aging in the eighties: Functional limitations of individuals age 65 years and older. National Center of Health Statistics AdvanceData 133. Dunlop, D.D., Hughes, S.L. & Manheim, L.M. (1997). Disability in activities of daily living: Patterns of change and a hierarchy of disability. American Journal of Public Health 87 (3): 378-383. Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975) Mini-mental state. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 12 (3): 89-98. Gerrard, P. (2013). The hierarchy of the activities of daily living in the Katz index in residents of skilled nursing facilities. Journal of Geriatric Physical Therapy 36 (2): 87-91. Gill T.M., Allore, H.G. & Han, I. (2006a). Bathing disability and the risk of long-term admission to a nursing home. Journal of Gerontology Series A: Biological Sciences and Medical Sciences 61A (8): 821-825. Gill, T.M., Guo, Z. & Allore, H.G. (2006b). The epidemiology of bathing disabilities in older persons. Journal of the American Geriatrics Society 54: 1524-1530. Guralnik, J.M., Simonsick, E.M., Ferrucci, L., Glynn, R.J., Berkman, L.F., Blazer, D.G., Scherr, P.A. & Wallace, R.B. (1994). A short physical performance battery assessing lower extremity function: Association with self-reported disability and prediction of mortality and nursing home admission. Journal of Gerontology 49 (2): M85-M94. Jette, A.M., Branch, L.G. & Berlin, J. (1990). Musculoskeletal impairments and physical disablement among the aged. Journal of Gerontology 45: M203-208. Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B.A. & Jaffe, M.W. (1963). Studies of illness in the aged. Journal of the American Medical Association 185:914-919. Katz, S., Downs, T.D., Cash, H.R. & Grotz, R.C. (1970). Progress in Development of the Index of ADL. The Gerontologist 10 (1): 20-30. Katz, S. & Akpom, A. (1976). A Measure of Primary Socio-Biological Functions. International Journal of Health Services 6 (3): 493-508. Kelly-Hayes, M., Jette, A.M., Wolf, P.A., D´Agostino, R.B. & Odell, P.M. (1992). Functional Limitations and Disability among Elders in the Framingham Study. American Journal of Public Health 82 (6): 841-845. Kubitschke, L., & Cullen, K. (2010). ICT & Ageing European Study on Users, Markets and Technologies. Brussels: European Commission. LaPlante, M.P., Harrington, C. & Kang, T. (2002). Estimating paid and unpaid hours of personal assistance services in activities of daily living provided to adults living at home. Health Services Research 37 (2): 397-415.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 18 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
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Lazaridis, E.N., Rudgerg, M.A., Furner, S.E. & Cassel, C.K. (1994). Do activities of daily living have a hierarchical structure? An analysis using the Longitudinal Study on Aging. Journal of Gerontology 49:M47-M51. Mahoney, F.L. & Barthel, D.W. (1965). Functional Evaluation: The Barthel Index. Maryland State Medical Journal 14: 61-65. Njegovan, V., Man-Son-Hing, M., Mitchell, S.L. & Molnar, F.J. (2001). The Hierarchy of Functional Loss Associated With Cognitive Decline in Older Persons. Journal of Gerontology: Biological Sciences and Medical Sciences 56A (10). M638-M643. O´Sullivan, S.B. & Schmitz, T.J. (2007). Physical rehabilitation. Philadelphia: Davis Company. Sainsbury, A., Seebass, G., Bansal, A. & Young, J.B. (2005). Reliability of Barthel Index when used with older people. Age and Ageing 34: 228-232. Siu, A.L., Reuben, D.B. & Hayes, R.D. (1990). Hierarchical measures of physical function in ambulatory geriatrics. Journal of the American Geriatrics Society 38: 1113-1119. Sonn, U. (1996). Longitudinal studies of dependence in daily life activities among elderly persons. Scandinavian Journal of Rehabilitation Medicine (Supplement) 34:1-35. Teng, E.L. & Chui, H.C. (1987). The modified mini-mental state (3MS) examination. Journal of Clinical Psychiatry 48: 314-318. Tombaugh, T.N. & McIntyre, N.J. (1992). The Mini-Mental State Examination: A Comprehensive Review. Journal of the American Geriatrics Society 40 (9): 922-935. Travis, S.S. & McAuley, W.J. (1990). Simple counts of the number of basic ADL dependencies for long-term care research and practice. Health Service Research 25:349-360. Wiener, J.M., Hanley, R.J., Clark, R. & Van Nostrand, J.F. (1990). Measuring the activities of daily living: Comparisons across national surveys. Journal of Gerontology 45 (6): S229-S237.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 19 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Appendix: Clinical assessments
The Index of ADL (Katz et al. 1963, Katz et al. 1970) The Index of ADL was developed to study results of treatment and prognosis in the elderly and chronically ill. The Index of Independence in Activities of Daily Living is based on an evaluation of the functional independence or dependence of patients in bathing, dressing, going to toilet, transferring, continence, and feeding. Independence means without supervision, direction, or active personal assistance, except as specifically noted below. This is based on actual status and not on ability. Table 1: Index of ADL – Description of independence and dependence Function Independent Dependent
Bathing Assistance only in one part (as back Assistance in bathing more than one part (Sponge, or disabled extremity) or bathes self of the body; assistance in getting in and shower, or tub) completely out of tub or does not bathe self.
Dressing Gets clothes from closet and drawers; Some help is necessary (with cutting up puts on clothes, outer garments, food, etc., as listed above). braces; manages fasteners; act of tying shoes is excluded.
Going to toilet Gets to toilet; gets on and off toilet; Uses bedpan or commode or receives arranges clothes; cleans organs of assistance in getting to and using toilet. excretion; (may manage own bedpan used at night only and may or may not be using mechanical supports).
Transfer Moves in and out of bed Assistance in moving in or out of bed independently and moves in and out and/or chair; does not perform one or of chair independently (may or may more transfers. not be using mechanical supports).
Continence Urination and defecation entirely self- Continence in urination or defecation; controlled. partial or total control by enemas, catheters, or regulated use of urinals and/or bedpans.
Feeding Gets food from plate or its equivalent Assistance in act of feeding (see above); into mouth; (precutting of meat and does not eat at all or parenteral feeding. preparation of food, as buttering bread, are excluded from evaluation)
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Horizon 2020 ICT-Supported Bath Robots
Table 1: Index of ADL Index Description A Independent in feeding, continence, transferring, going to toilet, dressing, and bathing. B Independent in all but one of these functions. C Independent in all but bathing and one additional function. D Independent in all but bathing, dressing, and one additional function. E Independent in all but bathing, dressing, going to toilet, and one additional function. F Independent in all but bathing, dressing, going to toilet, transferring, and one additional function. G Dependent in all six functions. Other Dependent in at least two functions, but not classifiable as C, D, E, or F.
The Barthel Index (Mahoney & Barthel 1965) The Barthel ADL index is an ordinal scale used to measure performance in basic activities of daily living (ADL). Each performance item is rated on this scale with a given number of points assigned to each level or ranking. It uses ten variables describing ADL and mobility. A higher number is associated with a greater likelihood of being able to live at home with a degree of independence following discharge from hospital. The amount of time and physical assistance required to perform each item are used in determining the assigned value of each item. Its effectiveness is not just with in-patient rehabilitation but home care, nursing care, skilled nursing, and community. The Barthel index has been shown to have portability and has been used in 16 major diagnostic conditions. The Barthel index has demonstrated high inter-rater reliability (0.95) and test–retest reliability (0.89) as well as high correlations (0.74–0.8) with other measures of physical disability.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 21 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 2: Barthel Index Function Score Description
Feeding 10 Independent. The patient can feed himself a meal from a tray or table when someone puts the food within his reach. He must put on an assistive device if this is needed, cut up the food, use salt and pepper, spread butter, etc. He must accomplish this in a reasonable time.
5 Some help is necessary (with cutting up food, etc., as listed above).
0
Transfer - Moving from wheelchair 15 Independent in all phases of this activity. Patient can to bed and return safely approach the bed in his wheelchair, lock brakes, lift footrests, move safely to bed, lie down, come to a sitting position on the side of the bed, change the position of the wheelchair, if necessary, to transfer back into it safely, and return to the wheelchair.
10 Either some minimal help is needed in some step of this activity or the patient needs to be reminded or supervised for safety of one or more parts of this activity.
5 Patient can come to a sitting position without the help of a second person but needs to be lifted out of bed, or if he transfers with a great deal of help.
0
Doing personal toilet 5 Patient can wash hands and face, comb hair, clean teeth, and shave. He may use any kind of razor but must put in blade or plug in razor without help as well as get it from drawer or cabinet. Female patients must put on own makeup, if used, but need not braid or style hair.
0
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Getting on and off toilet 10 Patient is able to get on and off toilet, fasten and unfasten clothes, prevent soiling of clothes, and use toilet paper without help. He may use a wall bar or other stable object for support if needed. If it is necessary to use a bed pan instead of a toilet, he must be able to place it on a chair, empty it, and clean it.
5 Patient needs help because of imbalance or in handling clothes or in using toilet paper.
0
Bathing 5 Patient may use a bath tub, a shower, or take a complete sponge bath. He must be able to do all the steps involved in whichever method is employed without another person being present.
0
Walking on a level surface 15 Patient can walk at least 50 yards without help or supervision. He may wear braces or prostheses and use crutches, canes, or a walkerette but not a rolling walker. He must be able to lock and unlock braces if used, assume the standing position and sit down, get the necessary mechanical aides into position for use, and dispose of them when he sits. (Putting on and taking off braces is scored under dressing.)
10 Patient needs help or supervision in any of the above but can walk at least 50 yards with a little help.
5 If a patient cannot ambulate but can propel a wheelchair independently. He must be able to go around corners, turn around, maneuver the chair to a table, bed, toilet, etc. He must be able to push a chair at least 50 yards. Do not score this item if the patient gets score for walking.
0
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Horizon 2020 ICT-Supported Bath Robots
Ascending and descending stairs 10 Patient is able to go up and down a flight of stairs safely without help or supervision. He may and should use handrails, canes, or crutches when needed. He must be able to carry canes or crutches as he ascends or descends stairs.
5 Patient needs help with or supervision of any one of the above items.
0
Dressing and Undressing 10 Patient is able to put on and remove and fasten all clothing, and tie shoe laces (unless it is necessary to use adaptations for this). The activity includes putting on and removing and fastening corset or braces when these are prescribed. Such special clothing as suspenders, loafer shoes, dresses that open down the front may be used when necessary.
5 Patient needs help in putting on and removing or fastening any clothing. He must do at least half the work himself. He must accomplish this in a reasonable time. Women need not be scored on use of a brassiere or girdle unless these are prescribed garments.
0
Continence of bowels 10 Patient is able to control his bowels and have no accidents. He can use a suppository or take an enema when necessary (as for spinal cord injury patients who have had bowel training).
5 Patient needs help in using a suppository or taking an enema or has occasional accidents.
0
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Horizon 2020 ICT-Supported Bath Robots
Controlling bladder = 10 Patient is able to control his bladder day and night. Spinal cord injury patients who wear an external device Urinary continence and leg bag must put them on independently, clean and empty bag, and stay dry day and night.
5 Patient has occasional accidents or can not wait for the bed pan or get to the toilet in time or needs help with an external device.
0
A score of 0 is given in all of the above activities when the patient cannot meet the criteria as defined above.
A patient scoring 100 BI is continent, feeds himself, dresses himself, gets up out of bed and chairs, bathes himself, walks at least a block, and can ascend and descend stairs. This does not mean that he is able to live alone. Despite abilities to perform basic ADLs he may still be limited in more complex instrumental Activities in daily living (IADL) or social contacts as he may not be able to cook, keep house, and meet the public, but he is able to get along without attendant care. The Barthel index is also used to operationalize the need of health care. Table 3: Barthel Index and the need of help Categories Barthel-Index Need of help
1 85 - 100 Selective need of help, nearly completely independent
2 35 - 80 Needy
3 0 – 30 Nearly completely dependent
Reference: MDK Kompetenz Centrum Geriatrie (http://www.kcgeriatrie.de/assessment_3.htm)
The Barthel index is used worldwide for classification of impairment levels in activities of daily living and has high predictive validity for loss of autonomy (Kelly-Hayes et al. 1992; Guralnik et al. 1994; Sonn 1996; Gill et al. 2006a).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 25 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Mini Mental State Examination (Folstein et al. 1975) The Mini Mental State Examination (MMSE) is an internationally well-established screening test for cognitive impairment to classify the cognitive status and allow comparability to other studies also including cognitive criteria. The test has proven high validity, reliability, feasibility to be used as a screening instrument (Folstein et al. 1975, Tombaugh & McIntyre 1992). The time to administer is about 10-15 minutes requesting only limited personal resources for assessment. For a screening tool, the MMSE allows a rather comprehensive documentation of cognitive sub-performances including memory (early-late recall, working memory), executive- and semantic performances, orientation in time and locus.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 26 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 27 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 28 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
2 Modelling user requirements and associated use case scenarios - the clinical perspective Authors: Dr. Jochen Werle, Prof. Dr. Klaus Hauer (Bethanien)
2.1 Introduction Health care in old age is becoming increasingly important due to the current socio-demographic changes as well as the development in health policy. The primary aim in health care is to insure that peoples’ life is as healthy and independent as possible while maintaining the best possible quality of life. Furthermore, the quality of medical and nursing care as well as an adequate and safe home environment is of high relevance. Technical innovations, e.g. Ambient Assisted Living (AAL) systems, offer increasing opportunities for an independent and self-determined way of life for older people living at home and in care facilities. The majority of potential AAL users are chronically ill and frail older persons. Thus, knowledge about their needs and medical prepositions is crucial for the collaboration of scientists and technicians. What is the situation of older people? How are their health conditions? Which kind of requirements and needs does this target group have? Which kinds of health problems limit the use of AAL-systems in daily living? A clinical model of user requirements for AAL project development will need a strong conceptual basis. Functionalities of the I-Support bath robot system will basically support impaired functions of potential users. Thus, we have chosen an internationally established classification and assessment system to describe these geriatric impairments. The International Classification of Functioning, Disability and Health (ICF) represents an efficient tool to assess peoples´ current functional health status (functioning) in daily life (WHO 2002). As such, the ICF constitutes a comprehensive concept for health care planning including multiple dimensions from body functions to personal activities, societal participation and environmental factors (WHO 2002). It provides the potential framework for transition along the continuum of care (Grill et al. 2011) and recent design studies of AAL tools, primarily based on analysis of activities in daily living (Matsumoto et al. 2011; Tanaka et al. 2013). The I-Support project aims to define user requirements for the development of an innovative bath robot system, based on impairments of body functions with high clinical relevance. In this part of the report (D 1.1) we describe a classification-/and evidence-based clinical model of bathing/showering disability which is the focus of the I-Support project. The preliminary user definition will be extended using additional criteria for the technical design. These are, in particular cognitive, motor and sensorial impairments of the user group, which are relevant for shower activities and specific system functionalities.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 29 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
In Section 2.2, we give a brief overview of the ICF as our conceptual model. In addition, we present a case study characterizing a person with bathing disability, and therefore a potential user of the projected I-Support bath robot system. In Section 2.3, we outline frequent geriatric impairments, based on a comprehensive ICF Core Set for geriatric patients, which have to be respected in the design process of the I-Support bath robot system. It is obvious that bathing/showering limitations may have different causes. Limited joint and bone mobility restrict the user´s ability to wash certain body parts. Impairments of neuromusculoskeletal and movement-related functions as well as sensorial functions, e.g. vestibular and proprioceptive functions, limit the user´s mobility and transfer to the shower including an increasing risk of falling. In addition, sensorial deficits and cognitive impairments complicate the usage of technical devices. In Section 2.4, we carve out the relevance of these frequent geriatric impairments for the definition of use case scenarios and system functionalities in a clinical model of impairments, limitations and user requirements.
2.2 International Classification of Functioning, Disability and Health (ICF) as framework for modeling user requirements The World Health Organization (WHO) has developed two reference classification systems to describe the health status of a person at a particular point in time (WHO 2004). Diseases and other health-related concerns are recorded with the International Classification of Diseases (ICD-10). ICD-10 is the standard diagnostic tool for epidemiology, health management and clinical purposes. It is used to monitor the incidence and prevalence of diseases and other health-related problems (WHO 2011). Medical therapies in acute events such as stroke, heart attack or fractures, request strictly disease-related therapy pathways. In contrast, the International Classification of Function, Disability and Health (ICF) comprises health domains and contemplates individual health conditions with its´ effects on daily life. The ICF represents a holistic, integrated bio-psycho-social model of human functioning and disability (WHO 2002). In terms of the ICF, a person is (functionally) healthy, when in front of her/his entire background (concept of context factors) her/his body functions (physiological functions) and body structures (anatomical parts) correspond with generally accepted standard values (concept of body functions and body structures), she/he does or can do all the things which are expected from people without health problems (concept of activities), and she/he can unfold her/his entity in all areas of life in a way it is expected from non-disabled people (concept of participation in areas of life).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 30 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
In summary, functional health/disability of a person represents the result of the interaction between the persons´ health conditions (ICD) and her/his perceived contextual factors. Contextual factors represent the complete background of an individual’s life and living. They include two components: environmental factors and personal factors. Environmental factors make up the physical, social and attitudinal environment in which people live and conduct their lives. These factors are external to individuals and can have a positive or negative influence on the individual’s performance as a member of society, on the individual’s capacity to execute actions or tasks, or on the individual’s body function or structure. Personal factors are the particular background of an individual’s life and living and comprise features of the individual that are not part of a health condition or health state. These factors include, among others, gender, race, age, other health conditions, fitness, lifestyle, habits, upbringing, coping styles, social background, education, profession, past and current experience (past life events and concurrent events), overall behavior pattern and character style, individual psychological assets and other characteristics, all or any of which may play a role in disabilities at any level. Personal factors are not explicitly classified in the ICF. Nevertheless, to show their contribution and their potential impact on the outcome of various interventions (WHO 2002), they are displayed in Figure 2-1.
Figure 2-1. The ICF model of disability (according to WHO 2002). Diseases as well as changes due to the ageing process are associated with disabilities resulting in persisting or temporary somatic changes of body functions and structures (concept of impairments) as well as psycho-social changes affecting activity (concept of limitations) or participation (concept of restrictions). Contextual factors as described above may affect functional health/disability in a positive (facilitators) or negative way (barriers).
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Horizon 2020 ICT-Supported Bath Robots
For a better understanding of the application of the ICF model for the I-Support design process, we provide a brief case study of a person with bathing/showering disability (according to BAR 2010).
Case history A 71-year old retired person, male, widowed and childless, living on the first floor in an old two-floor country house in a rural area. His 62-year old sister and her husband live on the second floor. They have no direct neighbors; the next farm is 1.5 km away, the nearest supermarket 3 km. The primary care physician lives 8 km away in a small village, his orthopedist and internist surgery in the city is 32 km away. The beginning dementia of our patient creates problems for his sister, who is limited in time because as well as caring for him, she still works in her part-time job. The patient fell off the ladder while picking cherries and fractured his right femoral hip. Before his accident he liked to work in the garden, and he is well-liked in his neighborhood because of his cheerful nature. Until two months ago he was happy to take his bike every Friday to join the regulars´ table in the village nearby. Medical care is provided through home visits by his primary care physician. The physiotherapist from the neighboring village, however, does not offer home visits. There is a poor public transport connection to the neighboring town and the next city: the bus only operates twice a day. Diagnoses: Acute: Medial fracture of the right femoral neck (ICD-10: S72.01) Total hip joint endoprosthesis (ICD-10: Z 96.8) Co-diagnoses: Osteoarthritis of the hip, on the right (ICD-10: M16.9) Osteoarthritis of the shoulder, on the left (ICD-10: M19.91) Hypertension (ICD-10: I11.90) Insulin-dependent diabetes mellitus (ICD-10: E12.90) Slight residual amyosthenia, on the right, following a stroke (M62.8) Beginning dementia (F03) Complaints: Limited walking distance up to 300m, only with walking stick Climbing stairs and bending down is possible slowly and with pain Needs of care in ADL (undressing, bathing/showering) Needs of care in IADL (preparing meals, financial management) Increasing disorientation (time and place) and impairment of memory
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Horizon 2020 ICT-Supported Bath Robots
Figure 2-2. ICF-oriented case study (according to BAR 2010).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 33 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
In terms of ICF, the description of disabilities is very comprehensive. This patient represents a multi-morbid older person, suffering from more than one chronic illness at the same time (health problems) with moderate frailty, defined as needs of care in ADL and IADL (limitations), due to his functional and cognitive impairments. The increasing impairments in intellectual functions (increasing disorientation, loss of memory) in combination with limited mobility (hip, shoulder, spine) and muscle weakness (impairments) represent the main causes for his bathing/showering limitations. In addition, walking and transferring problems have to be considered in the assessment of his functional status. For the design of the I-Support bath robot system impairments of physiological functions, e.g. high blood pressure and metabolic disorders can be neglected as well as contextual factors. In the near future the I-Support bath robot system will be a positive environmental factor, facilitating bathing/showering activities.
It is the changes of body functions and structures (impairments), which are specifically targeted in a rehabilitation process and it is these changes that trigger the design of the I-Support bath robot system. Therefore, in the next section we give a short overview of the ICF strategies to assess functions and disabilities. 2.2.1 Assessment of functions and disabilities – ICF Core Sets The ICF provides the comprehensive framework to describe and assess functions and disabilities of a person in several health domains. ICF codes utilize an alphanumeric system to describe health and health-related domains, with the following letter codes: b=body functions, s=body structures, d=activities and participation, e=environmental factors. The letters are followed by a numeric code that starts with a one digit chapter number followed by a second level denoted by two-digits, and third and fourth levels represented by one digit each. (WHO 2002). Comprising over 1400 second-level categories, the entire volume of the ICF cannot be applied by the clinicians to all their patients. In order to enhance the applicability of the ICF in clinical practice and research as well as to overcome practical concerns relating to the high number of categories provided within the ICF, the development of ICF Core Sets was recently initiated by the ICF Core Set projects (Bickenbach et al. 2012). Those comprehensive ICF Core Sets were created to provide standards for a multi-professional comprehensive patient assessment, and include the typical spectrum of problems in functioning encountered in different patient populations (Stier- Jarmer et al. 2011). The ICF Core Set development involved a formal decision-making and consensus process, integrating evidence gathered from preliminary studies including focus groups of health professionals, a systematic review of the literature and empiric data collection from patients. Fifteen secondary users selected a total of 123 second-level categories for the first comprehensive ICF Core Set for geriatric patients in early post-acute rehabilitation facilities (Grill et al. 2005).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 34 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Using a sample of 209 patients Grill et al. (2011) identified candidate categories for a brief ICF Core Set for patients in geriatric early post-acute rehabilitation facilities, subdivided in 38 categories. The brief ICF Core Set represents a practical alternative to the lengthy comprehensive sets. It provides a minimal standard for measuring and communicating patients’ functioning. For the design of the I-Support bath robot system the ICF Core Sets have to be adapted to define user requirements and describe use case scenarios from a clinical perspective. Therefore, we give a description of frequent geriatric impairments in section 2.3, which have to be considered in the design process of the I-Support bath robot system.
2.3 Description of frequent geriatric impairments In a geriatric population, using the ICF Core Set, most prevalent disabilities were found in the health domain “activities”, primarily moving around (80%), walking (79%), washing oneself (75%), caring for body parts (74%) or dressing (73%). They are closely linked with frequent impairments in associated categories of “body functions”, such as gait pattern functions (73%), muscle power functions (73%), mobility of joint functions (59%) and sensation of pain (57%) (Stier-Jarmer 2011). As mentioned above, bathing/showering disability may have different causes, cognitive as well as motor and sensorial impairments. Therefore, we selected the most relevant second-level categories concerning bathing/showering limitations from the comprehensive ICF Core Set for geriatric patients (see Figure 2-3). Below, we give a brief report of epidemiological and clinical data, related to these frequent geriatric impairments, which have to be considered in the I-Support design process.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 35 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 2-3.Potential impairments of body functions affecting bathing/showering activities
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 36 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
In terms of ICF, bathing/showering activities and limitations are encoded as d510 “washing oneself”. As described above, the alphanumeric codes give us a clear structure: Because the I-Support bath robot system provides assistance in impaired functions, we focus on impairments of body functions (ICF code = b). The first digit describes the main chapters of the classification system. For the development of the I-Support bath robot system we identified six main categories of functional impairments that affect bathing/showering (i.e., mental functions, sensory functions/pain, movement-related functions, skin functions, and urination/defecation functions). In the left and right column, we listed the most relevant impairments of body functions (second-level categories) concerning limitations of bathing/showering activities. 2.3.1 Mental functions (b1) This ICF chapter is summarizing the functions of the brain: both global mental functions, such as consciousness (b110), orientation (b114), intellectual functions (b117), energy and drive (b130), and specific mental functions, such as attention (b140), memory (144), psychomotor functions (b147), emotion (b152), perception (b156), language (b167) and calculation (b172) (WHO 2007). Impairments of mental (cognitive) functions have an overall importance for IADL and subsequently for ADL performance (Njegovan et al. 2001) as well as for the interaction with care givers or assistive devices (McGilton et al. 2007). Cognitive impairment is highly associated with old age, but its´ early stages are often undiagnosed despite the high risk of progression to dementia with ageing. Recent epidemiological studies from European countries yielded prevalence rates of 10% to 25% for mild cognitive impairment (MCI) in patients aged 65 years and older in western industrialized nations, with a mean prevalence of approximately 16% (Panza et al. 2005). The incidence rates of all prodromal dementia syndromes were found to increase with age from 1% to 5% at the age of 65 years to 30% to 50% at the age of 80 years and older (Ritchie & Lovestone 2002). Compared to representative populations, this rate is significantly higher in populations where cognitive impairment is a leading cause of admission, e.g. in nursing homes, or in populations with a high comorbidity including age-associated cognitive decline, e.g. in rehabilitation settings (Ziegler & Doblhammer 2008). Age-related changes in cognitive functions negatively impact tasks related to both basic and instrumental activities of daily living. Njegovan et al. (2001) studied the hierarchy of functional loss associated with cognitive decline in older adults. Those persons who showed a cognitive decline during a 5-year period had significantly larger decline in functional status compared to those who did not show cognitive decline. Bathing as basic ADL is comparable to more complex IADL, e.g. shopping, transportation or meal preparation. For the I-Support project this is a remarkable result: Bathing, especially with an ICT-supported bath robot system, is as complex as other IADLs with a high impact of mental functions. Therefore, mental functions that have to be taken in consideration when designing the I-Support bath robot system are as follows: Orientation functions (b114), Attention functions (b140), Memory functions (b144), Emotional functions (b152),
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 37 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Basic cognitive functions (b163), Higher-level cognitive functions (b164). 2.3.1.1 Orientation functions (b114) This ICF code describes general mental functions of orientation to time, space, place and person, orientation to self and others, and disorientation to time, place and person (WHO 2007). Orientation for time was the only Mini Mental State Examination (MMSE) domain for which poor baseline performance was significantly associated with faster rate of decline in the total MMSE score after controlling for age, sex, and education. Poor orientation for time doubled the rate of decline in the MMSE (Guerrero-Berroa et al. 2010). Orientation for time and place were the domains with the largest extent of change over time in patients with Alzheimer Dementia (Small et al. 1997). In a geriatric population, 15% of the patients in post-acute rehabilitation facilities have impaired functions of orientation (Stier-Jarmer et al. 2011). 2.3.1.2 Attention functions (b140) Within this ICF category are encoded specific mental functions of focusing on an external stimulus or internal experience for the required period of time, including functions of sustaining, shifting, dividing and sharing attention, concentration and distractibility (WHO 2007). Older adults show significant impairments on attentional tasks that require dividing or switching of attention among multiple inputs or tasks. They show relative preservation of performance on tasks that require selection of relevant stimuli; and although they are slower than young adults, they are not differentially impaired by distraction (Verhaeghen & Cerella 2002). They also are able to maintain concentration for an extended period of time. The tasks on which older adults show impairments tend to be those that require flexible control of attention (Glisky 2007). 18% of geriatric patients reported impairments of attention functions at admission in a post-acute rehabilitation center (Stier-Jarmer et al. 2011). 2.3.1.3 Memory functions (b144) Memory functions represent specific mental functions of registering and storing information and retrieving it as needed. This ICF category comprises functions of short-term and long-term memory, immediate, recent and remote memory, memory span, retrieval of memory, remembering, as well as functions used in recalling and learning (WHO 2007). The cognitive domain that has probably received the most attention in normal aging is memory (Glisky 2007) representing also the leading symptom for dementia diagnosis. Many older adults complain of increased memory lapses as they age, and a major focus of research has been to try to distinguish memory declines attributable to normal aging from those that are indicative of pathological aging, particularly Alzheimer’s disease. Like attention, memory is not a unitary construct; some sub-types of memory remain relatively intact with age or during the course of disease while others show significant and/or early decline. Short-term or primary memory involves the simple maintenance of information over a short period of time. Older adults show minimal or no
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 38 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
deficits in short-term memory (Glisky 2007). Working memory is a multidimensional cognitive construct that has been hypothesized as the fundamental source of age-related deficits in a variety of cognitive tasks, including long-term memory, language, problem-solving, and decision-making (Glisky et al. 2007). Long-term memory as well is a cognitive domain with various dimensions. It seems that the episodic memory is the most affected by normal aging, while other subdomains, e.g. semantic and prospective memory show no age-related deficits (Glisky et 2007). Within a geriatric population of post-acute patients, impaired memory functions were assessed in 22% of post-acute patients (Stier-Jarmer et al. 2011). 2.3.1.4 Basic and higher-level cognitive functions (b163, b164) Basic cognitive functions comprises mental functions, which are involved in the acquisition of knowledge about objects, events and experiences; and the organization and application of that knowledge in tasks requiring mental activity (WHO 2007). Higher-level cognitive functions often called executive functions, comprising complex goal-directed behaviors such as decision-making, abstract thinking, planning and carrying out plans, mental flexibility, and deciding which behaviors are appropriate under what circumstances. Functions of abstraction and organization of ideas, time management, insight and judgement, as well as concept formation, categorization and cognitive flexibility are included (WHO 2007). In the past decade, there has been an increasing focus on executive control as a primary contributor to cognitive decline with age (Glisky 2007). Executive control is a multi-component construct that consists of a range of different processes that are involved in the planning, organization, coordination, implementation, and evaluation of many of our non-routine activities. It is particularly important for novel tasks for which a set of habitual processes is not readily available (Glisky 2007). Relatively little research has been done on the effects of aging on decision-making. Most of the work has highlighted the potential impact of attentional and working memory limitations on the ability to make decisions. Decision-making seems to be a domain that makes clear demands on processing resources, but in everyday life those demands may be reduced by life- relevant knowledge or expertise in the problem-solving domain. Poor decision-making may also be a result of episodic memory decline, particularly the loss of memory for details or source (Glisky 2007). In a study population of older patients with neurological conditions, the prevalence of impairments of higher-level cognitive functions amounted up to 56% (Müller et al. 2011). 2.3.1.5 Emotional functions (b152) This ICF category includes specific mental functions related to emotions and affective components of the processes of the mind: functions of appropriateness of emotion, regulation and range of emotion; affect; sadness, happiness, love, fear, anger, hate, tension, anxiety, joy, sorrow; lability of emotion; flattening of affect (WHO 2007). In a geriatric population, impairments of emotional functions, e.g. depression, anxiety, fatigue, are relatively frequent (Luppa et al. 2012). For example, the prevalence of major depression ranges from 4.6% to 9.3% (pooled prevalence 7.2%), and that of depressive disorders from 4.5% to 37.4% (pooled prevalence 17.1%) (Luppa et al. 2012). Clinically relevant anxiety symptoms occurred in
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 39 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
21.0% of community-dwelling older adults aged 74+, which were significantly associated with depression, physical morbidity and female gender. Further, there were significant associations with a consumption of alcohol exceeding one alcoholic unit per day (Forlani et al. 2014). For the clinical model of impairments, limitations and user requirements, we will focus on fear of falling as a main risk factor for falling and associated activity restriction (Delbaere et al. 2010; Denkinger et al. 2014). Fear of falling For a long time, the fear of falling (FOF) was believed to be a result of the psychological trauma of a fall, also called "post-fall syndrome" (Legters 2002). This syndrome was first mentioned in 1982 by Murphy and Isaacs, who noticed, that after a fall ambulatory persons developed walking disorders as well as intense emotional dysfunction. Fear of falling has been identified as one of the key symptoms of this syndrome. Since that time, FOF has gained recognition as a specific health problem among older adults. However, FOF was commonly found among elderly persons who had not yet experienced a fall (Suzuki et al. 2002). A systematic review found that the prevalence of fear of falling in community-dwelling older adults ranged from 21% to 85% (Scheffer et al. 2008) due to deviating study samples and definition/assessment strategies. An earlier review found the prevalence varied by falls history, ranging from 12% to 65% in community-dwelling older adults who had not fallen and from 29% to 92% in those who had fallen (Legters 2002). In a more recent comprehensive systematic review, Denkinger et al. (2014) analyzed factors associated with fear of falling and their consequences for activity restriction in community-dwelling older adults. The only parameters robustly associated across all constructs of FOF were female gender, performance-based and questionnaire-based physical function, the use of a walking aid, and, less robust, a history of falls and poor self-rated health. Conflicting results were identified for depression and anxiety, multiple drugs, and psychotropic (Denkinger et al. 2014). The consequences of fear of falling include falling, restriction or avoidance of daily activities, loss of independence, reduction in social activity, depression and a reduction in quality of life (Delbaere et al. 2010; Legters 2002). 2.3.1.6 Consequences for bathing/showering activities As mentioned above, using the I-Support bath robot system is as complex as other ADLs with a high impact of mental functions. Older people with cognitive impairments and less technical experience are often unsettled when using technical equipment or communication devices and techniques, associated with fear avoidance belief patterns and a feeling of helplessness. Therefore the projected I-Support bath robot system may have to guide and give assistance to mentally impaired older persons during the shower process (e.g. with clear voice instructions). The required system functionalities may have to be summarized in a special use case scenario.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 40 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
2.3.2 Neuromusculoskeletal and movement-related functions (b7) The ICF encodes motor functions as neuromusculoskeletal and movement-related functions (b7), including the functions of movement and mobility as well as functions of joints, bones, reflexes and muscles (WHO 2007). Impaired performance-based physical function is strongly associated with the onset of functional dependence (Gill et al. 1995). For the design of the I-Support bath robot system the following neuromusculoskeletal and movement-related functions may have to be considered: Mobility of joint and bone functions (b710, b720), Muscle power functions (b730), Involuntary movement reaction functions (b755), Control of voluntary movement functions (b760), Gait pattern functions (b770). 2.3.2.1 Mobility of joint and bone functions (b710, b720) Mobility of joint functions comprises functions of the range and ease of movement of a single or several joints (vertebral, shoulder, elbow, wrist, hip, knee, ankle, small joints of hands and feet), including impairments such as in hypermobility of joints, frozen joints, frozen shoulder and arthritis (WHO 2007). Mobility of bone functions encodes functions of the range and ease of movement of the scapula, pelvis, carpal and tarsal bones as well as impairments such as frozen scapula and frozen pelvis (WHO 2007). Body tissues and joints change with advancing age, which can lead to limitations in range of motion (Goldberg & Neptune 2006), movement (Prince et al. 1997) and normal daily functioning (Stathokostas et al. 2013). Upper body flexibility is known to be important for several activities, such as getting dressed and reaching for objects. On the other hand, lower body flexibility is important for maintaining normal and secure walking patterns and for activities involving bending and reaching (Spirduso et al. 2005). A decrease in flexibility of the shoulder and hip joints by approximately 6 degrees per decade was observed across ages 55 to 86 years in both men and women (Stathokostas et al. 2013). Analysis of age subgroups showed that both shoulder and hip joints begin to experience significant declines after 70 years. In general, females have greater flexibility than males throughout life (Bell & Hoshizaki 1981). About 60% of geriatric patients reported comprehensive impairments in mobility of joints (Stier-Jarmer et al. 2011). 2.3.2.2 Muscle power functions (b730) Muscle power functions describe functions related to the force generated by the contraction of a muscle or muscle groups, e.g. functions associated with the power of specific muscles and muscle groups, muscles of one limb, one side of the body, the lower half of the body, all limbs, the trunk and the body as a whole. Impairments such as weakness of small muscles in feet and hands, muscle paresis, muscle paralysis, monoplegia, hemiplegia, paraplegia, quadriplegia and akinetic mutism are also included (WHO 2007). Loss of muscle power functions is a prevalent impairment of older persons based on age- associated degeneration of skeletal muscle mass (sarcopenia), leading to an average decrease of
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 41 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
maximal strength of 10% to 15% per decade (Frontera et al. 2000; Frontera et al. 2012). In a prospective cohort study, measures of lower-extremity function (b7303) were highly predictive of subsequent disability in persons aged 71+ years, who did not show disabilities at baseline. Lower scores at baseline were associated with a statistically significant increase in the frequency of disability in activities of daily living and mobility-related disability at follow-up (Guralnik et al. 1994; 1995). In a geriatric population, the prevalence of impairments in muscle power functions is 75% (Stier- Jarmer et al. 2011). 2.3.2.3 Involuntary movement reaction functions (b755) Within this ICF category, functions of involuntary contractions of large muscle groups, induced by body position, balance and threatening stimuli and includes functions of postural reactions, righting reactions, body adjustment reactions, balance reactions, supporting reactions and defensive reactions were encoded (WHO 2007). In ICF categories involuntary movement reaction functions comprises postural control. Pyykkö et al. (1990) examined postural control in elderly subjects aged 85 years and older. When compared with a group of 50-60-year-old subjects, elderly people showed significantly higher sway velocities. Postural control is reduced as one result of loss of sensory cues of presso-receptors and deterioration in reflex-function initiated by muscle spindles (Pyykkö et al. 1990). Poor balance control is a major risk for falling (Rubenstein 2006). At least 30% of geriatric patients in post-acute rehabilitation facilities reported impairments in involuntary movement reaction functions (Stier-Jarmer et al. 2011). 2.3.2.4 Control of voluntary movement functions (b760) This ICF code comprises functions associated with control over and coordination of simple and complex voluntary movements as well as supportive functions of the arm or leg, right left motor coordination, eye hand coordination, eye foot coordination (WHO 2007). A loss of function affects, in particular, fine hand use (performing the coordinated actions of handling objects), and hand and arm use (performing the coordinated actions required to move objects or to manipulate them by using hands and arm). In a German longitudinal study of an adult population in motor coordination a loss of 16% to 22% per decade was observed, with higher rates in the age of 60 years and older (Woll 2002, Tittlbach 2002). The prevalence rate of impairments of control of voluntary movement functions in a geriatric population is about 20% (Stier-Jarmer 2011). 2.3.2.5 Gait pattern functions (b770) Gait pattern functions summarizes functions of movement patterns associated with walking, running or other whole body movements and encodes impairments such as spastic gait, hemiplegic gait, paraplegic gait, asymmetric gait, limping and stiff gait pattern (WHO 2007). Age associated changes of physiological and neurological functions affect walking performance (Prince et al. 1997). Changes are difficult to determine due to a lack of standards of normal walking
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 42 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
in older persons (Alexander 2002). Gait pattern functions are highly associated with muscle power functions (b730), involuntary movement reaction functions (b755), vestibular and proprioceptive functions (b235, b260), and mental (cognitive) functions (b1). Deviations of normal gait patterns originates from different causes, which include sensory deficits, neurodegenerative processes, toxic factors (drugs, alcohol) and fear of falling (Jahn et al. 2010). Effects of cognitive impairment on gait patterns are described in all subtypes of dementia, even in early and preclinical stages (O´Keeffe et al. 1996; Scherder et al. 2007). Approximately 35% of community-dwelling persons, aged 70 years and older, present with abnormal gait patterns (Verghese et al. 2006). The prevalence increases for persons living in nursing homes (Salzman 2010). Stier-Jarmer et al. (2011) reported gait pattern impairments in 70% of geriatric patients in rehabilitation facilities. 2.3.2.6 Consequences for bathing/showering activities Impairments of motor functions affect bathing/showering in different ways. In terms of ICF, impairments of mobility of joint and bone functions (b710, b720) and impairments of control of voluntary movement functions (b760) may cause limitations in bending (d4105) and reaching (d4452), as well as limitations in fine hand use (d440) and hand and arm use (d445). Limitations in fine hand use include picking up (d4400), grasping (d4401), manipulating (d4402), while limitation in hand and arm use includes pulling (d4450), reaching (d4452) and turning or twisting (d4453). These activities play an important role in the use of the I-Support bath robot system, e.g. while operating the remote control and/or steering the motions of the soft arm. In addition, based on limitations in range of motion (bending, reaching), several use case scenarios for the showering process of body parts have to be defined. Impairments of muscle power functions (b730) and involuntary movement reaction functions (b755; postural control) as well as gait abnormalities (b770) can be associated with limitations in changing or maintaining basic body position (d410, d415), transferring oneself (d420), walking and moving (d450, d455, d460). Gait abnormalities are a major risk for fear of falling and falls (Tinetti et al. 1990). Bathrooms have been identified as a hazardous location (Stefanacci & Haimowitz 2014): 65.8 per 100.000 bathroom injuries occurred in or around the tub or shower. The precipitating events in 37.3 % of injuries were bathing (excluding slipping while bathing), showering, or getting out of the tub or shower. Only 2.2% occurred while getting into the tub or shower. The precipitating event for 17.3% of injuries was slipping, which included slipping while bathing, and 5.5% were attributed to an antecedent loss of consciousness (Stefanacci & Haimowitz 2014). It is essential, that the I-Support bath robot system provides corresponding safety functionalities with use case scenarios for stand-to-sit/sit-to-stand transfer, for transition inside-outside the shower area, and for postural control while standing and sitting as well as emergency strategies (for loss of consciousness and/or falls).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 43 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
2.3.3 Sensory functions and pain (b2) This chapter of the ICF comprises all functions of the senses, e.g. seeing, hearing, tasting, as well as the sensation of pain (WHO 2007). Motor functions, as described above, are closely linked to sensorial functions of the kinesthetic system. In addition, hearing and visual impairments have strong and independent impacts on subsequent physical, mental and social functioning (Wallhagen et al. 2001). Impairments in either of these senses have the potential to disrupt interpersonal relations and severely constrain social participation. Lupsakko et al. (2002) found an association between combined hearing and visual impairment and depressive symptoms in a population aged 75 years and older. Furthermore, visual impairment is a risk factor for falls and fall injuries in older adults (Kallstrand-Ericson & Hildingh 2009; Wang et al. 2012). Hearing and vision impairments are common in older adults (Harwood et al. 1998) and of increasing incidence with advancing age (Gunnlaugsdottir 2009). Compared to physical limitations, the onset of perceptual impairments of seeing and hearing functions (b210, b230) occurred later in life. Such sensorial limitations do not impact older adults’ ability to perform ADLs and IADLs as much as physical limitations (Seidel et al. 2009). However, several relevant ADLs and IADLs would be difficult to perform with vision or hearing impairments (Rogers et al. 1998), e.g. preparing meals, dressing, and moving around (Seidel et al. 2009). For the design of the I-Support bath robot system the following perceptual body functions may have to be considered: Seeing functions (b210), Hearing functions (b230), Vestibular functions (b235), Sensations associated with hearing and vestibular function (b240), e.g. dizziness (b2401), Proprioceptive functions (b260), Sensory functions related to temperature and other stimuli (b270), Sensation of pain (b280). 2.3.3.1 Seeing functions (b210) The ICF defines seeing functions as sensory functions relating to sensing the presence of light and sensing the form, size, shape and color of the visual stimuli, including visual acuity functions, visual field functions, quality of vision, functions of sensing light and color, visual acuity of distant and near vision, monocular and binocular vision and visual picture quality (WHO 2007). Seidel et al. (2009) analyzed data from a longitudinal, population-based study. At baseline there was an overall prevalence of vision impairments of 15.3% with a higher prevalence reported by women (17.4%) and increasing with age (8.2% in the age group 65-69 to 34.2% for persons, aged 85 years and older). The Salisbury Eye Evaluation project investigated the impact of vision on functional status in a population-based sample of elderly persons. A random sample including 65 to 84 year-old men and women from Salisbury, Maryland was recruited for home interviews and clinical examinations. The proportion of persons with a binocular visual acuity worse than 20/40
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 44 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
increased dramatically with age from 4.1% in the age group 65-69 years to 16.0% in the age group 80+ years. Visual acuity impairment was significantly related to all measures of functional status. Furthermore, visual impairment was one of the most important predictors for the absence of social activities (West et al. 1997). In addition, the proportion of people wearing eye glasses increases with age from 73% in the age group between 45 and 59 years to 93% in the age group 60+ years (Allensbach 2011). 2.3.3.2 Hearing functions (b230) Within this ICF category are encoded sensory functions relating to sensing the presence of sounds and discriminating the location, pitch, loudness and quality of sounds. It includes functions of hearing, auditory discrimination, localization of sound source, lateralization of sound, speech discrimination as well as impairments such as deafness, hearing impairment and hearing loss (WHO 2007). Hearing loss ranks as the third-most-prevalent chronic disability in persons aged 65 and older, being experienced by approximately 24% of those aged 65 to 74 years, by 33% of those 70+ years, and by up to 39% of those over the age of 75 years, based on self-reports (Wallhagen et al. 2001). However, the high prevalence of hearing impairment among older persons, its increase with age, and its higher prevalence among men compared to women have been supported by a community-based study that used pure-tone audiometric testing, with hearing loss defined as an average loss over four frequencies >25 decibels in the worse ear (Cruickshanks et al. 1998). In contrast to visual deficits, hearing impairment was not associated with ADL disability (Rudberg et al. 1993) or had a less extensive effect on physical functioning (Wallhagen et al. 2001; Dargent- Molina et al. 1996). Nevertheless, hearing impairments affects the use of communication devices and overall communication functions. 2.3.3.3 Vestibular functions (b235) This ICF category includes sensory functions of the inner ear related to the registration of body position, balance and movement, e.g. functions of position and positional sense; functions of balance of the body and movement (WHO 2007). Agrawal et al. (2012) determined a global decline in vestibular function associated with aging. The degeneration of vestibular end organ functions is a main reason for imbalance in the elderly (Hsieh et al. 2014). In a study population of US adults aged 40 years and older 35.4% had vestibular dysfunctions, and prevalence rates of vestibular dysfunction increased significantly with age (Agrawal et al. 2009). 2.3.3.4 Sensations associated with hearing and vestibular function (b240) Sensations of dizziness, falling, tinnitus and vertigo are included in this ICF category (WHO 2007). Dizziness and imbalance are one of the most common complaints among older people. The prevalence ranges from approximately 20% to 30%, depending on the definition of dizziness and the population investigated (Iwasaki & Yamasoba 2015). A population-based study in the United States found that 24% of people older than 72 years reported having an episode of dizziness within the previous two months, lasting for at least one month (Tinetti et al. 2000). Another population-based study in the United Kingdom reported that 30% of people older than 65
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 45 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
years have dizziness (Colledge et al. 1994a). The prevalence of dizziness has a tendency to increase with age (Tinetti et al. 2000; Colledge et al. 1994a). A cross-sectional study in Sweden reported that the overall prevalence of balance problems at the age of 70 years was 29% for men and 36% for women. Balance impairments related to vestibular dysfunction were more common among women than men, and increased with age. At ages 88–90 years, the corresponding values were 45% for men and 51% for women. The most common symptom was poor balance/general unsteadiness (11% to 41%), rotatory symptoms occurred in 2% to 17% (Jönsson et al. 2004). Dizziness is a major risk for problems with balance and gait, and the resulting risk of falling (Tinetti et al. 2000). 2.3.3.5 Proprioceptive functions (b260) Proprioceptive functions describe sensory functions of sensing the relative position of body parts, including functions of statesthesia and kinaesthesia (WHO 2007). Already in the year 1906 Sherrington originally described proprioception as the perception of joint and body movement as well as position of the body/body segments in space. At present, proprioception comprises the cumulative neural input to the central nervous system from specialized nerve endings called mechanoreceptors. Mechanoreceptors are located in the joints, capsules, ligaments, muscles, tendons, and skin. The somatosensory system, and specifically the proprioceptive system are critically involved in the sensory control of balance. Colledge et al. (1994b) studied the relative contributions of vision, proprioception, and the vestibular system on postural control in different age groups. They found that all age groups were more dependent on proprioception than on vision for the maintenance of balance. Thus, impaired proprioception could be a contributing factor to falls in a rehabilitative setting (Mion et al. 1989). There is evidence of proprioception deterioration with aging (Kaplan et al. 1985; Pai et al. 1997; Ribeiro & Oliveira 2007). The prevalence of impairments of proprioceptive functions in geriatric patients is 14% (Stier-Jarmer 2011). 2.3.3.6 Sensory functions related to temperature and other stimuli (b270) The ICF code comprises sensory functions related to temperature and other stimuli, including functions of being sensitive to temperature, vibration, shaking or oscillation, superficial and deep pressure, burning sensation or a noxious stimulus (WHO 2007). Older persons have a reduced cutaneous thermal sensitivity, and especially a reduced subjective thermal perception during cooling (Smolander 2002). In addition, the ability to make physiological adjustments when exposed to low or high temperatures decreases with age (Vogelaere & Pereira 2005). Physiological responses to cold environment induce a reversible plasma water shift from the intravascular to the interstitial and intracellular level due to peripheral vasoconstriction. This phenomenon occurs on exposure to cold water or air and even during facial cooling by a cold wind. Persons exposed to cold must increase their heat production to maintain their body temperature, based on thermogenesis, or by producing metabolic heat. However, thermogenesis appears to decrease with advancing age (Vogelaere & Pereira 2005).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 46 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Heat tolerance declines with age. Above-normal temperatures induce a reduction in intravascular water due to sweating. Older people are less able to cope with the increased viscosity of blood and are thus more liable to suffer a cardiovascular accident. Furthermore, older people react to heat with increased peripheral blood flow, but their maximum capacity is lower, and therefore they suffer from heat exhaustion (Vogelaere & Pereira 2005). Impairments of sensory functions related to temperature and other stimuli were reported by 13% of geriatric patients (Stier-Jarmer 2011). 2.3.3.7 Sensation of pain (b280) In this ICF category sensations of unpleasant feeling indicating potential or actual damage to some body structure and sensations of generalized or localized pain (in one or more body part) are classified, as well as impairments, such as myalgia, analgesia and hyperalgesia (WHO 2007). In a clinical setting, we distinguish between acute and chronic pain. Acute pain is a normal sensation that alerts to possible injury. In contrast, chronic pain is identified as any pain lasting more than 12 weeks. It often persists for months or even longer (National Institutes of Health 2011). A chronic pain syndrome may arise from an initial injury or there may be an ongoing cause, such as illness or psychological stress. However, there may also be no clear cause. Other health problems, such as fatigue, sleep disturbance, decreased appetite, and mood changes, often accompany chronic pain. Chronic pain may limit a person’s movements, which can reduce flexibility, strength, and stamina. This difficulty in carrying out important and enjoyable activities can lead to disability and despair (National Institutes of Health 2011). Chronic pain of moderate to severe intensity occurs in 19% of adults in Europe, seriously affecting their daily activities and their quality of life. It is more common in women, older people, and people with relative deprivation (Breivik et al. 2006). In a geriatric population, 57% of the patients reported sensations of pain (Stier-Jarmer 2011). 2.3.3.8 Consequences for bathing/showering activities Impairments of sensorial functions may cause bathing/showering limitations in many ways. Functions of the kinesthetic system, including vestibular functions (b235), sensations associated with hearing and vestibular function (b240) and proprioceptive functions (b260) are closely linked with motor functions, which may lead to limitations in changing or maintaining basic body position (d410, d415), transferring oneself (d420), walking and moving (d450, d455, d460). As mentioned above, use case scenarios supporting transfer, transition and posture are essential for the I- Support bath robot system. Mainly impairments of seeing functions (b210), due to the fact that people normally do not wear eye glasses while showering, but also impairments of hearing functions (b230) affect communication functions (d310, d315) and the use of communication devices and techniques (d360), e.g. remote controls. Because of high prevalence rates of visual and hearing impairments, it is indispensable for the development of the I-Support bath robot system to define a use case scenario for sensorial impaired people.
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Horizon 2020 ICT-Supported Bath Robots
Base settings of the I-Support bath robot system (air and water temperature, pressure of the water jet) have to be adjusted with respect to impairments of sensory functions related to temperature and other stimuli (b270) as well as sensations of pain (b280). Physiological responses may cause stress for older persons (d240) and require subsequent modifications of base settings. This process has to be described in a specific use case scenario. 2.3.4 Functions of the skin and related structures (b8) In this chapter the ICF encodes functions of skin, nails and hair (WHO 2007). The skin is the largest organ of the human body with a body weight percentage of 12% to 16%. In contrast to the internal organs, the skin is in direct contact with the environment, including UV radiation, ozone, and atmospheric pollution (Makrantonaki et al. 2012). Ageing skin undergoes progressive degenerative change. Structural and physiologic changes that occur as a natural consequence of intrinsic aging combined with the effects of a lifetime of ongoing cumulative extrinsic damage and environment insult (e.g. overexposure to solar radiation) can produce a marked susceptibility to dermatologic disorders in the elderly (Farage et al. 2009). 2.3.4.1 Protective functions of the skin (b810) The ICF category includes functions of the skin for protecting the body from physical, chemical and biological threats, e.g. functions of protecting against the sun and other radiation, photosensitivity, pigmentation, quality of skin, insulating function of skin, callus formation, and hardening. In addition, impairments such as broken skin, ulcers, bedsores and thinning of skin are encoded (WHO 2007). The elderly predominately suffer from dry skin, eczema dehydration with itching, wrinkling and pigment spots up to skin tumors. In addition, irritated-toxic eczema in body wrinkles, caused by obesity and sweating, and skin irritations, caused by incontinence and small wounds occur very frequently (Proksch 2015). In a geriatric population, about 30% of the patients are affected from impairments of protective functions of the skin (Stier-Jarmer 2011). 2.3.4.2 Consequences for bathing/showering activities Dry skin is stressed by frequent showers by losing important fats and moisture. The acid mantle, which protects the skin from external influences, is damaged by any shower on dry skin. From a clinical perspective, a use case scenario “Skin care” may represent a valuable functionality of an innovative bath robot system. 2.3.5 Urination and defecation functions (b620, b525) Urination functions comprises functions of urination, frequency of urination, urinary continence and impairments such as in stress-, urge-, reflex-, overflow-, continuous incontinence, dribbling, automatic bladder, polyuria, urinary retention and urinary urgency (WHO 2007). Defecation functions include functions of elimination, fecal consistency, frequency of defecation, fecal continence, flatulence as well as impairments such as constipation, diarrhea, watery stool and anal sphincter incompetence or incontinence (WHO 2007).
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Horizon 2020 ICT-Supported Bath Robots
Urinary incontinence frequently coexists with fecal incontinence in nursing home residents (Nelson et al. 1998). Urinary and/or fecal incontinence are serious problems for elderly people with high impact on their quality of life ranging from social isolation to institutionalization (Lifford et al. 2008). 2.3.5.1 Urinary continence (b6202) Urinary incontinence (UI) refers to any involuntary leakage of urine. There are several types, the most common being stress incontinence, urge incontinence, mixed incontinence and overflow incontinence (Abrams et al. 2002). Another type of UI is overactive bladder, which is a collective concept for increased frequency and urgency, with or without leakage (Abrams et al. 2002). UI is one of the most common health problems in women, with an estimated prevalence varying from 17% to 55% (Thom 1998). UI has medical and psychological consequences, including social isolation, impaired quality of life, depression, and institutionalization (Lifford et al. 2008). The prevalence of male urinary incontinence ranges between 5.4% and 15%. Urgency incontinence is the predominant subtype in all age groups, although the relative proportion shifts towards stress incontinence with rising age. Neurological and posttraumatic causes for male stress incontinence become less important as the frequency of iatrogenic interventions (radiation, prostate surgery) increase. Additional risk factors for male urinary incontinence are age, immobility, and neurological diseases (Hampel et al. 2010). 2.3.5.2 Fecal continence (b5253) Fecal incontinence (FI) is a chronic, debilitating condition resulting from an inability to effectively restrict the passage of fecal material through the anal canal. This leads to loss of control over bowel movements and, in severe cases, involuntary defecation. FI leads to severe impairment of the quality of life, frequent infectious medical complications and overwhelming psychological stress to the patient and his or her family. The reported incidence of FI varies worldwide (Nevler 2014). The prevalence and incidence of FI has been assessed in different settings: the community, nursing home, and hospital setting. Older estimates of FI ranged from 2% to 17% in the community setting (Nelson et al. 1995; Edwards & Jones 2001, Whitehead et al. 2009). FI has an even higher prevalence in the elderly, at 6% to 9% (Johanson & Lafferty 1996; Teunissen et al. 2004; Townsend et al. 2013). A more recent study has indicated that the problem may affect more people than previously known. That is 36.2 % of patients reported to suffer from FI (Shah et al. 2012). FI is more common in older patients. In a community-dwelling population, 17% of patients who were continent at baseline developed an FI after 4 years (Markland et al. 2010). In the nursing home setting, the rates of FI rise from 33% to 65% (Markland et al. 2010; Nelson et al. 1998; Hägglund 2010). 2.3.5.3 Consequences for bathing/showering activities For impaired patients personal hygiene, e.g. bathing and showering of sensitive regions (d520, d530), is indispensable. From a clinical perspective use case scenarios for intimate care (core region, posterior region) have to be defined. In the following Section 2.4 we summarize the evidence-based description of geriatric impairments in a clinical model of impairments of body functions, limitations of activities and user requirements,
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Horizon 2020 ICT-Supported Bath Robots
concerning the bathing/showering process. The consequential, clinically relevant use case scenarios will be derived directly from the user requirements that will be described below.
2.4 Modeling of user requirements and use case scenarios The technical requirements for an innovative bath robot system are very complex. From a clinical perspective, we focus on needs of potential users, based on frequent impairments of body functions and associated limitations of activities. The bathing/showering process consists of many different activities, which users have to perform from entering the shower until leaving it again. The shower process in itself is the core process, but the transfer and transition process are of similar importance. In the last section, we described frequent geriatric impairments with their consequences for the bathing/showering process. In this section, we carve out the relevance of these impairments for the definition of use case scenarios and system functionalities in a clinical model of impairments, limitations and user requirements (Figure 2-4). It represents an extension of the previous model (Figure 2-3). Based on the description of impairments of body functions, we describe in detail which activities or limitations of activities affect the preliminary I-Support bathing process. Except for defecation and urination functions, we use the second-level categories used in the previous section.
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Horizon 2020 ICT-Supported Bath Robots
Figure 2-4. I-Support: Model of impairments, limitations and user requirements
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 51 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Age-related diseases and/or inadequate use (inactivity, overload) may cause several functional impairments. These impairments are listed as second-level codes in the left column. Mental functions: Orientation (b114), attention (b140), memory (b144), basic cognitive functions (b163), higher-level cognitive functions (b164), emotional functions (b152). Neuromusculoskeletal functions: Mobility of joint and bone functions (b710, b720), control of voluntary movement functions (b760), muscle power functions (b730), involuntary movement reaction forces (b755), gait pattern functions (b770). Sensorial functions: Vestibular functions (b235), sensations associated with hearing and vestibular functions (b240), proprioceptive functions (b260), seeing functions (b210), hearing functions (b230), sensory functions related to temperature and other stimuli (b270), sensations of pain (b280). Functions of the skin: Protective functions of the skin (b810). Defecation and urination functions: Fecal incontinence (b5253), urinary incontinence (b6202). Those impairments are often followed by limitations of activities. As listed in the middle column, limitations concerning the bathing/showering process are more complex than expected. For the design of an innovative bath robot system, it is not sufficient to focus on self-care functions alone. It is also essential to provide functionalities for limitations, concerning the transfer and transition to the shower area as well as the communication with the system. In our model, user requirements can directly be derived from specific impairments and limitations. In the right column, impairment-related user requirements for the I-Support bath robot system are listed. For example, impairments of mobility of joint and bone functions (b710, b720) together with impairments of control of voluntary movement functions (b760) subsequently lead to limitations in fine hand use (d440) as well as hand and arm use (d445), which might be important for the control of the motions of the I-Support soft arms. Assistance in controlling the motion of soft arms has to be defined as user requirement. Impairments of seeing and hearing functions (b210, b230) cause limitations in communication functions (d360, d310, d315). Sensorial assistance is the corresponding user requirement.
The following paragraph gives detailed information as to the user requirements defined in Figure 2-4 (right column). This will be the basis for potential use case scenarios, based on clinical perspective. Cognitive assistance As mentioned before, bathing represents a complex ADL/IADL with a high impact of cognitive functions, especially in the context of an ICT-supported, sophisticated bath robot system. Therefore, cognitive status was identified as main inclusion criterion for the I-Support user definition (see Chapter 2 of D 1.1). Persons with advanced impairment levels (MMSE <18) will be excluded from the project. People with no or moderate cognitive impairments, particularly when they have less technical experience, might have limitations using communication and technical devices (d360) properly, associated with a feeling of helplessness and fear avoidance strategies. Within the I-Support development process, this issue has to be considered in the design of all system functionalities. Ease of use, safety and automation are requested standards for the complete sequence of the I- Support shower process. Furthermore, the I-Support bath robot system may have to provide strategies and functionalities
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Horizon 2020 ICT-Supported Bath Robots
to adjust base settings, to provide clear and safe operating instructions, to navigate older persons through the transfer and shower process, for example with verbal instructions to avoid fears and a feeling of helplessness, to support subsequent modifications of base settings, to provide emergency strategies (e.g. fall detection), to include gesture/speech recognition. Some of the suggested technical requirements have been addressed in previous AAL studies. For example, LoPresti et al. (2008) dealed with assistive technologies for cognition, especially memory and orientation, and Saegusa et al. (2014) described audio-visual feedback to assist people’s cognitive activities. More recently AAL projects present functionalities for fall detection (Volkhardt et al. 2013; Stone & Skubic 2015), gesture detection (Gouthaman et al. 2014) and heart rate monitoring (Wijaya et al. 2014). Shower assistance Showering represents the core process of the I-Support bath robot system. From a clinical perspective, it is essential to maintain the user´s independence in parts of her/his activities as long as possible. The I-Support system will provide as much technical support as needed, dependent on the user´s abilities and preferences, leaving remaining abilities to be still trained and used in the showering process. For this reason, we defined four use case scenarios, based on user abilities and impairments: Core region, Distal region, Back region, Posterior region. The core region includes body parts, which the user in a sitting position, is able to wash herself/himself with low risk exposure or little effort. The Core region includes abdomen, chest, arms, front of thighs and genitals. Intimate hygiene independently is very important for the elderly. For washing this sensitive body part, the soft arms of the I-Support system may only have assistive functions as passive water hose and as robotic arm to give the user washing tools or drying towels. The distal region comprises lower thighs from knee joints downwards and feet. For washing these body parts, the user has to bend forward with a high risk of losing postural control. The I-Support bath robot system has to perform the distal region shower process automatically. The back region is expanding from the cervical spine to the tailbone. Due to limitations of reaching this body part, the I-Support bath robot system may have to provide a functionality for a fully automatically back region shower process. The posterior region includes back of thighs and the backside (buttock). As described in section 2.3.5 urinary and/or fecal incontinence are serious problems for many older persons, and intimate care is indispensable. It is not possible to wash back of thighs and backside comprehensively while
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Horizon 2020 ICT-Supported Bath Robots
sitting. For this reason, a use case scenario “Posterior region shower process” may have to provide functionalities for sit-to-stand and stand-to-sit transfer as well as postural control while standing. The development of such technical assistive technologies for bathing procedures has a long tradition on which the I-Support project may draw on. At the 1970 World Expo in Osaka, a Japanese Electronics Group, introduced a first concept of a washing machine for humans, officially named Ultrasonic Bath, which found no access to the market. Due to lack of demand, the production of a descendant of the Ultrasonic Bath concept (2004) called the HIRB ("Human In Roll- lo Bathing") system was also stopped (http://gizmodo.com/5150593/sanyos-human-washing- machine-from-1970). More recent design studies deal with mechatronic systems for assistance on bath of bedridden elderly people (Bezerra et al. 2015; Yukawa et al. 2010) and the development of a head care robot (Hirose et al. 2013). In addition, some rehabilitation robots have functionalities to support activities of daily living, including grooming, shaving and bathing (Balaguer et al. 2005; Smarr et al. 2010). In a future step within the I-Support project, clinical partners (Bethanien) in cooperation with other project partners will perform a systematic review to collect available information on comparable projects. Motion control of the soft arm Bathing/showering with an ICT-supported bath robot system is not only cognitively demanding. It also requires well-trained motor control capabilities. For older persons the fine hand use as well as the hand and arm use is limited. Modeling the user´s intention and movements in complex motions of the soft arms is a prior challenge in the design process of the I-Support bath robot system. The I-Support bath robot system may have to provide functionalities to assist the user to shower (based on learned motion primitives), to control the soft arm motions. The engineering of complex movement control architectures based on motion primitives has been a central development in recent years towards adaptive and flexible control of complex and compliant robots (e.g. Nordmann et al. 2015; Mandery 2015). Another AAL project has gained experience using a remote control for the operating of a robot assisted rehabilitation system (Ohkubo et al. 2010). Transfer, transition and posture assistance A loss of muscle strength, postural control and gait abnormalities caused by an age-related loss of muscle mass and a decline of vestibular and proprioceptive functions represent intrinsic risk factors for falling. For the acceptance of the I-Support bath robot system, due to the high prevalence of falls in the bathing environment, it is essential to give the potential user a secure feeling, in particular while entering and leaving the shower cabin, during stand-to-sit and sit-to- stand transfers and maintaining a secure sitting position during the shower procedure. The hardware of the I-Support bath robot system may have to provide functionalities for stand-to-sit/ sit-to-stand transfer,
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Horizon 2020 ICT-Supported Bath Robots
transition into/out of the shower area, postural control. A previous study experienced with assistance strategies during standing, walking and seating operations for robotic walkers (Chugo et al. 2009). In addition, a sanitary company designed flexible bathing solutions, including a motorized chair with two degrees of freedom: height adjustment and vertical transition (Pressalit; http://de.pressalit.com). Sensorial Assistance Perceptual impairments did not seem to impact older adults’ ability to perform ADLs and IADLs as much as motor impairments did (Seidel et al. 2009). However, for the design and operation of an assistive bath robot system, perceptual impairments represent a serious problem. When using the shower, persons usually do not wear eye glasses or hearing aids. It is essential that people with poor vision are able to operate the I-Support bath robot system correctly. High safety standards should ensure that operator errors do not result in increased accidents and injury due to sensory deficits, e.g. the adjustment of water temperature. Hearing impairment in older persons requires additional system adaptations for the human-robot- communication tools of the I-Support system. It has to be considered, that the I-Support bath robot system is providing sufficient font sizes and brightness as well as voice control functions for persons with visual impairments, is adjusting signals or alerts with respect to persons with hearing impairments. It has to be considered that annoying signals and alarms promote confusion in older persons or in persons with cognitive impairments. For some system functionalities previous AAL projects provide preliminary solutions for voice control strategies (Nishimori et al. 2007; Dubey et al. 2014; Mishra et al. 2015). In addition, some projects deal with mechatronic devices, supporting learning of people with visual and hearing impairments (Quek et al. 2013; Armin et al. 2014). Base settings and system adjustment Older persons have a reduced thermal sensivity, especially during cooling, and a decreased thermogenesis (Vogelaere & Pereira 2005). For this reason, they freeze very quickly. In addition, heat exposure may extend cardiac sensations. These issues may have to be considered in the adjustment of the base settings, e.g. air and water temperature, pressure of the water jet, and length of the shower process. Deviations may cause short-term risks for the health of old and frail users. The recognition of the users´ behavior during the shower process is essential. Appropriate functionalities of the I-Support bath robot system are user perception, gesture recognition, voice recognition and interpretation.
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Horizon 2020 ICT-Supported Bath Robots
Previous studies have gained experience with corresponding functionalities, for example with the MS Kinect system for the user perception (El-Laithy et al. 2012), a smart watch based on motion sensors for gesture detection (Gouthaman et al. 2014), and different voice control strategies for rehabilitative devices (Dubey et al. 2014), personal assistant robots (Mishra et al. 2015) and intelligent wheelchairs (Nishimori et al. 2007). Skin care Impairments of protective functions of the skin have a twofold impact on the design of the I-Support bath robot system. First, as mentioned before, the elderly frequently suffer from dry and vulnerable skin, which is stressed by frequent showers. From a clinical perspective, skin care is an additional user requirement for an innovative bath robot system. For the technical realization basically two options are conceivable: First, the addition of appropriate care lotions into the water, and second, the use of the soft arm (shower wiper) for applying a care lotion. An appropriate design study of a skin-care robot system has already been published (Tsumaki et al. 2008). Second, the I-Support bath robot system will be designed to take on functions of care givers. While showering naked persons, skin diseases and irritations can be detected by health professionals at an early stage. These irritations/diseases would otherwise normally be recognized by rare assessment routines such as the annual routine of skin cancer screening. Optional functionalities of the I-Support bath robot system may therefore be to assist the user in skin care, to detect skin irritations. Transition to potential use case scenarios In the comprehensive model above (Figure 2-4), we described user requirements, based on frequent geriatric impairments and associated limitations of activities. These user requirements serve as a basis for the definition of use case scenarios from a clinical perspective. In the following table (see Table 2-1 below) we summarize impairments and associated potential use case scenarios for the I-Support project.
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Horizon 2020 ICT-Supported Bath Robots
Table 2-1. Use case scenarios and system functionalities from a clinical perspective User requirements System functionalities Use case scenarios
Cognitive assistance To adjust base settings Operation and control of system functionalities To provide clear and safe operating instructions To navigate older persons through the transfer and shower process To support subsequent Subsequent modification of base modifications of base settings settings To provide emergency strategies Emergency procedures
Shower assistance To assist the user to shower Core region shower process
To assist the user to dry Distal region shower process herself/himself To control the motion of the soft Back region shower process arm(s) Posterior region shower process
Transfer, transition and To provide physical assistance Stand-to-sit/Sit-to-stand transfer posture assistance during stand-to-sit/sit-to-stand transfer To assist the user during transition Transition into/out of the shower into/out of the shower area area To provide postural control
To provide emergency strategies Emergency procedures
Sensorial assistance To support user with visual Visual control impairment To provide adequate communi- cation tools for user with hearing Human-Robot communication impairment Skin Care assistance To assist the user in skin care Skin care
To detect skin irritations Skin inspection The table gives an overlook on user requirements, associated system functionalities, and potential use case scenarios.
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Horizon 2020 ICT-Supported Bath Robots
2.5 Summary Based on the International Classification of Functioning, Disability and Health (ICF) as an internationally established conceptual framework we described a comprehensive model of impairments, limitations and user requirements, which may represent the basis for the definition of use case scenarios from a clinical perspective. The preliminary use case scenarios will be amended by the identification of user behaviors and attitudes from a qualitative perspective as identified by qualitative interviews and quantitative data collection (Frankfurt University of Applied Sciences). Final use cases will be described in cooperation with technical partners including their technical perspective and identification of functionalities. In a systematic review, which we plan to perform during the project, we will summarize the methodology of previous technical approaches, with focus on included functionalities/use cases, assessment methods and study design, relevant for projected validation studies of upcoming prototypes within the I-support project.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 58 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
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This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 59 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
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This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 60 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
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This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 61 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
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This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 62 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Kousaka, H., Mizoguchi, H., Yoshikawa, M., Tanaka, H. & Matsumoto, Y. (2013). Role analysis of dominant and non-dominant hand in daily life. Proceedings of the IEEE International Conference on Systems, Man, and Cybernetics, Manchester, UK, 2013: 3972–3977, Legters, K. (2002). Fear of falling. Physical Therapy 82, 264-272. Lifford, K.L., Townsend, M.K., Curhan, G.C., Resnick, M.L. & Grodstein, F. (2008). The epidemiology of urinary incontinence in older women: Incidence, progression, and remission. Journal of the American Geriatrics 56 (7), 1191-1198. LoPresti, E.F., Bodine, C. & Lewis, C. (2008). Assistive technology for cognition. Understanding the needs of persons with disabilities. IEEE Engineering in Medicine and Biology Magazine 27 (2), 29-39. Luppa, M., Sikorski, C., Luck, T., Ehreke, L., Konnopka, A., Wiese, B., Weyerer, S., König, H. & Riedel-Heller, S. (2012). Age- and gender-specific prevalence of depression in latest-life – Systematic review and meta-analysis. Journal of Affective Disorders 136 (3), 212-221. Lupsakko, T., Mantyjarvi, M., Kautiainen, H. & Sulkava, R. (2002). Combined hearing and visual impairment and depression in a population aged 75 years and older. International Journal of Geriatric Psychiatry 17, 808-813. Makrantonaki, E. , Liakou, A.I., Eckardt, R., Zens, M., Steinhagen-Thiessen, E. & Zouboulis, C.C. (2012). Hauterkrankungen beim geriatrischen Patienten. Epidemiologische Daten. Hautarzt 63 (12), 938-946. Mandery, C., Terlemez, Ö., Do, M., Vahrenkamp, N. & Asfour, T. (2015). The KIT whole-body human motion database. Advanced Robotics (ICAR), 17th International Conference on Advanced Robotics (ICAR), 27-31 July, Istanbul, Turkey. Markland, A.D., Goode, P.S., Burgio, K.L., Redden, D.T., Richter, H.E., Swayer, P. & Allman, R.M. (2010). Incidence and risk factors for fecal incontinence in black and white older adults: a population-based study. Journal of the American Geriatrics Society 58 (7), 1341-1346. Matsumoto, Y., Nishida, Y., Motomura, Y. & Okawa, Y. (2011). A concept of needs-oriented design and evaluation of assistive robots based on ICF. 2011 IEEE International Conference on Rehabilitation Robotics, Rehab Week Zurich, ETH Zurich Science City, Switzerland, June 29 - July 1. McGilton, K., Wells, J. Teare, G., Davis, A., Rochon, E., Calabrese, S. Naglie, G. & Boscart, V. (2007). Rehabilitating patients with dementia who have had a hip fracture. Part I: Behavioral symptoms that influence care. Topics in Geriatric Rehabilitation 23 (2), 161-173. Mion, L.C., Gregor, S., Buettner, M., Chwirchak, D., Lee, O. & Paras, W. (1989). Falls in the rehabilitation setting: incidence and characteristics. Rehabilitation Nursing 14 (1), 17-22. Mishra, A., Makula, P., Kumar, A., Karan, K. & Mittal, V.K. (2015). A voice-controlled personal assistant robot. International Conference on Industrial Instrumentation and Control (ICIC), May 28-30, College of Engineering Pune, India.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 63 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
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This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 64 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
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This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 65 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
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This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 66 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Townsend, M.K., Matthews, C.A., Whitehead, W.E. & Grodstein, F. (2013). Risk factors for fecal incontinence in older women. The American Journal of Gastroenterology 108 (1), 113-119. Tsumaki, Y., Kon, T., Suginuma, A., Imada, K., Sekiguchi, A., Nenchev, D.E., Nakano, H. & Hanada, K. (2008). Development of a skincare robot. 2008 IEEE International Conference on Robotics and Automation, May 19-23, Pasadena, California, USA,. Verghese, J., LeValley, A., Hall, C.B., Katz, M.J., Ambrose, F.D. & Lipton, R.B. (2006). Epidemiology of gait disorders in community-residing older adults. Journal of the American Geriatrics Society 54 (2), 255-261. Verhaeghen, P. & Cerella, J. (2002). Aging, executive control, and attention: a review of meta- analyses. Neuroscience and Biobehavioral Reviews 26 (7), 849-857. Vogelaere, P. & Pereira, C. (2005). Thermoregulation and aging. Revista portuguesa de cardiologia 24 (5), 747-761. Volkhardt, M., Schneemann, F. & Gross, H.M. (2013). Fallen person detection for mobile robots using 3D depth data. IEEE International Conference on Systems, Man, and Cybernetics. DOI 10.1109/SMC.2013.609. Wakita, Y., Tanaka, H. & Matsumoto, Y. (2014). Analysis and design of service robots based on ICF. Proceedings of the 2014 IEEE International Conference on Robotics and Biomimetics December 5-10, Bali, Indonesia. Wallhagen, M.I., Strawbridge, W.J., Shema, S.J., Kurata, J. & Kaplan, G.A. (2001). Comparative impact of hearing and vision impairment on subsequent functioning. Journal of the American Geriatrics Society 49, 1086-1092. Wang, M.Y., Rousseau, J., Boisjoly, H., Schmaltz, H., Kergoat, M.J. , Moghadaszadeh, S., Djafari, F. & Freeman E.E. (2012). Activity limitation due to a fear of falling in older adults with eye disease. Investigative Ophthalmology & Visual Science 53 (13), 7967-7972. West, S.K., Munoz, B., Rubin, G.S., Schein, O.D., Bandeen-Roche, K., Zeger, S., German, P.S. & Fried, L.P. (for the SEE project team) (1997). Function and visual impairment in a population- based study of older adults. The SEE Project. Investigative Ophthalmology & Visual Science, 38 (1), 72-82. Whitehead, W.E., Borrud, L., Goode, P.S. et al. (2009). Fecal incontinence in US adults: epidemiology and risk factors. Gastroenterology 137 (2), 512-517. Wijaya, R., Setijadi, A., Mengko, T.L. & Mengko, R.K.L. (2014). Heart rate data collecting using smart watch. IEEE 4th International Conference on System Engineering and Technology (ICSET) November 24-25, Bandung – Indonesia. Woll, A. (2002). Sporting activity in CV and their effects on the development of fitness and health - an international longitudinal study. Universität Karlsruhe: Habilitationsschrift.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 67 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
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World Health Organization (2002). Towards a common language for functioning, disability and Health (ICF). Geneva: World Health Organization. World Health Organization (2004). Family of International Classifications: definition, scope and purpose. Geneva: World Health Organization. World Health Organization (2007). International Classification of Functioning, Disability, and Health. Children & Youth Version. Geneva: World Health Organization. World Health Organization (2011). International Statistical Classification of Diseases and Related Health Problems. 10th Revision. Volume 2 Instruction manual 2010 Edition. Geneva: World Health Organization. Yukawa, T., Nakata, N., Obinata, G. & Makino, T. (2010). Assistance system for bedridden patients to reduce the burden of nursing care (First report – Development of a multifunctional electric wheelchair, portable bath, lift, and mobile robot with portable toilet). 2010 IEEE/SICE International Symposium on System Integration (SII 2010), 21 - 22 Dec, Sendai, Japan. Ziegler, U. & Doblhammer, G. (2009). Prevalence and incidence of dementia in Germany. A study based on data from the statutory health insurance. Rostock Center: Discussion paper No. 24.2009.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 68 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
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3 User abilities and needs Authors: Prof. Dr. Barbara Klein, Sarah-Sabrina Kortekamp, Holger Roßberg (FRA-UAS)
3.1 Introduction Acceptance of technical aids and assistive technologies is influenced by a variety of factors. It is widely acknowledged that the ease of use and perceived usefulness are essential key parameters (Claßen, 2012). However, they do not explain why for example personal alarm systems are not widely accepted although they are easy to use and contribute to more safety for independent living. A recent study on acceptance showed that gender culturally shaped life styles influence acceptance and usage of these technologies (Klein, Reutzel & Roßberg, 2015). The very often found belief that a person is willing to use assistive devices in order to enable or enhance independence and quality of life, is not mirrored in the actual practice of individuals (Klein et al., 2015). Most people see personal hygiene as one of the most private affairs. Support in washing is often connected with shame/prudency and asking for support is prolonged as possible. Developing an ICT-Supported bath robot seems to be a viable solution – at least from the perspective of very frail people. Objectives for Frankfurt University of Applied Sciences (FRA-UAS) are to analyse and define user and carer / resp. healthcare professionals’ requirements from all perspectives, incl. privacy, sociological and gender aspects. Developing a new product is subject to the process of requirements engineering. One of the most promising methodologies for user requirements analysis is Design Thinking as it can contribute to a systematic approach for users and relevant stakeholders. In the following the methodological approach and methods for the first user analysis are presented. 30 primary users and 15 healthcare professionals were interviewed with interview guidelines. The results are presented and conclusions drawn for the requirements of the I-Support System. In order to achieve these objectives, FRA-UAS draws back on the methodology of the Design Thinking Method.
3.2 Method 3.2.1 Design Thinking Method The Design Thinking Method is one of the promising approaches to shorten the product development process and to integrate user and stakeholders’ requirements. Design Thinking can be viewed as an attitude which enables a successful approach for the development of innovative products. Developing according to Design Thinking requires an empathic understanding of user needs and early product ideas, mockups, prototypes which are evaluated with users in several iterative processes (Gürtler & Meyer, 2013; Plattner, Meinel & Leifer, 2015) as Figure 3-1 shows.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 69 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 3-1. Iterative Design Process (cf. Gürtler, J. & Meyer, J, 2013)
In the European I-SUPPORT project Design Thinking is implemented as it is seen as necessary in order to understand the complexity and the level of intimacy of the showering process. Objective of I-SUPPORT is to develop an intelligent robotic shower system in order to support primarily users who are very frail or suffer from functional loss in their personal hygiene. Alternatively, it might be also used in inpatient healthcare institutions. Developing such a system implies an empathic understanding of the needs and requirements of the primary user, i.e. the person who is (very) frail and/or is suffering from functional loss. Also, it is critical to understand the tasks, needs and requirements from the perspective of the secondary user, i.e. care staff and professionals in the healthcare sector as well as the interests of relevant stakeholders. Therefore, a range of methods is utilized.
3.2.2 Methods applied for the user requirement analysis “Living” the Design Thinking Method as an attitude required for the I-Support-Project to get to work into and to know how people wash, bath and shower themselves and what are their pitfalls and wishes. The I-Support Team at FRA-UAS started analyzing journals on wellness, bathing etc. as well as professional nursing care literature, historical reports in order to understand this daily activity beyond own routine experiences. During this preliminary stage discussions and interviews with elderly, handicapped and professionals and also trend scouting with experts in industry took place. E.G. at the ISH, the world’s leading trade fair for sanitation and heating technology 2015, Frankfurt am Main or the AAL Congress with Exhibition on Future Living (Zukunft Lebenräume) , Frankfurt am Main. This information provided the basis to develop interview guidelines for primary users (elderly persons) and secondary users (healthcare professionals). They were tested with people from the target groups, coordinated and tuned with the consortium members and revised in iterative circles. This process was very time consuming, however it had the effect that very professional material for the interviews with the primary and secondary users could be created. The material for the interviews included:
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 70 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Brief information on the EU-Project ICT-Supported bath robots Informed consent forms Interview guideline for primary / resp. secondary users Pictures and videos of the I-Support System First Mock up and samples of material The informed consent form was developed together with Prof. Dr. Andrea Ruppert who is the chief privacy officer at FRA-UAS. The form had also several iterative cycles, in the end it was decided to phrase the form in easy language in order to be understandable for all interviewed client groups. Qualitative interviews with 30 primary users (e.g. frail, elderly persons) and 15 secondary users (formal and informal cares, healthcare professionals) took place in order to understand the showering process with its pitfalls and in consideration of different perspectives (culture, gender, age, etc.). Also, the target groups were asked for feedback on first drafts and materials of the I- Support system. Complying with the Design Thinking Method the background of the team members at FRA-UAS is multidisciplinary: sociology (Prof. Barbara Klein), business administration (Holger Roßberg) and cognitive science/human factors engineering (Sarah-Sabrina Kortekamp). The overall approach is qualitative and not quantitative and does not include any clinical assessments. Objective of the survey was to build up knowledge on the showering process and its influencing factors and obtaining early feedback on I-SUPPORT ideas and materials. Although the samples were convenience samples the team set parameters for age resp. functional loss, gender and cultural background for the primary users in order to obtain a heterogeneous sample. Selection criteria for secondary users were a broad selection of health backgrounds and experience. Results of these surveys are not representative. Interviews of primary users took place either in their private home or in the Independent Living Center at FRA-UAS according to their wishes. In general interviews of secondary users took place either at their workplace or in the Independent Living Center at FRA- UAS according to their wishes. 3.2.3 Outlook The results of these first analysis feeds into the technological development of the I-Support system. Further rendering, mockups, and prototypes will be discussed and exchanged in workshops with stakeholders and potential producers in order to get a feedback on the next developmental stage. Focus groups with primary and secondary users as well as stakeholders and potential producers will be held in order to get an early feedback on the first and second prototype. These are also a valuable means for preparing the pilot studies at Bethanien in Germany and FSL in Italy. These pilot studies will be performed with potential users in geriatric clinical environments to evaluate usability and acceptance of the developed prototypes 1 and 2.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 71 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
3.2.4 Wording and definitions In order to ease reading this section provides the definition of central terms: Primary Users. Primary Users are frail senior users with first problems with ADL, especially with bathing/taking a shower (Annex B, p. 5). Secondary Users. Secondary users of the I-SUPPORT system are formal and informal carers of primary users, including medical staff of all kinds, nurses, next-of-kin, etc. (Annex B, p. 5). Stakeholder. Business/Industrial stakeholders: (Smart) house constructors, bath designers/ providers, bath equipment and automation providers, integrated service/solutions, assistive technology providers. (Annex B, p. 36) The I-SUPPORT system consists of several parts. Therefore it might be helpful to define and describe what name refers to what part of the system. Shower arm. The system contains two robotic arms that are able to pour water and/or to soap the user. Both of these arms are referred to as “shower arm” (cf. Figure 3-2). It is not yet clear whether both shower arms can fulfil all possible tasks, i.e. both shower arms can attach a gripper for soaping, and also a shower head for pouring water. The other possibility is that one shower arm is always used for pouring water and the other can switch between tools like sponge or gripper. Materials. The shower arms’ technology consists of hollow tubes. By varying the air pressure the shower arms are able to move. The coating of the shower arms can consist of different substances, colours, etc. A selection of different materials suitable for coating the shower arms was used during the interviews (cf. Figure 3-3). Tools. Tools can be attached to the shower arms, e.g. a gripper or a sponge (cf. Figure 3-2). Shower head. For the sake of convenience, shower hose will be defined as a tool used for pouring water, similar to the gripper and sponge.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 72 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Shower arm
Gripper (tool)
Sponge (tool)
Figure 3-2. Overview of the shower arm, and two attachable tools (gripper and sponge).
Figure 3-3. Case with materials.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 73 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
3.2.5 Participants Two kinds of user groups were interviewed. On the one side the primary users, i.e. people with difficulties during the showering process and on the other side professional carers, physiotherapists, gerontologists and other professionals in the healthcare area as secondary users for showering processes and physical abilities of the primary users. Thirty primary users were interviewed, from which 17 were female and 13 were male. Age ranges from 46 to 90 (AM=70.47, SD=10.8). Since cultural and religious differences are evaluated, the sample comprises people from six different countries (e.g. Germany, Turkey and Japan; cf. Table 3-1) and five different religions (e.g. Protestants, Roman Catholics, Muslims, Buddhists; cf. Table 3-1).
Table 3-1. The number of primary users from different countries and religions, interviewed for the I-SUPPORT project. Origin Country of No Religion of primary No the primary users users Germany 21 Protestants 9 Turkey 4 Roman Catholics 7 Japan 2 Muslims 5 Serbia 1 Buddhists 2 Czechoslovakia 1 Orthodox Catholics 1 Afghanistan 1 None 6
Fifteen secondary users, secondary users in the healthcare sector, were interviewed, from which 10 were female and 5 were male. Age ranges from 35 to 64 (AM=51.07, SD=7.68). Field of work comprises qualified nurses, medical doctors, gerontologists, physiotherapists, and care home management. Work experience ranges from 4.5 to 40 years (AM=24, SD=11.09). The acquisition of primary and secondary users was undertaken via e-mail-lists and snowball technique. Thus, the samples are not representative. Primary users were contacted via personal contact and the mailing list of U3L (University of the Third Age at the Johann Wolfgang Goethe University Frankfurt am Main), via e-mails sent to the 21 nursing care homes of the AWO Hessen Süd e.V. and to Johanna Kirchner Altenhilfezentrum and August-Stunz-Zentrum, both AWO Bezirksverband Frankfurt am Main. Also, ambulatory/domiciliary services were contacted via personal approach and e-mail contact lists.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 74 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Primary and secondary users interviewed were asked whether they could recommend other possible interview partners. Associations, nursing care homes and ambulatory/domiciliary services and members of the university in the healthcare sector were contacted. There was no compensation for the interviews. However, primary users received a natural sponge as “Thank you” and secondary users were given the book “Future Bath” (ZVHSK Zentralverband Sanitär Heizung Klima & Zebner, 2015) about a universal design research project of the Sanitation, Heating and Air Conditioning Association and the Offenbach School of Design under the aspect of Universal Design. 3.2.6 Interview Guidelines The interview materials included written brief information about the project, an informed consent form, the interview guideline, pictures and videos of the I-SUPPORT system, as well as the mockup arm and a range of materials for the shower hose. Development of the interview guidelines was based on an iterative process. This included discussions and briefing with secondary users about essential aspects of showering processes, especially for the frail elderly, information on general problems with showering elderly people, as well as analysing questionnaires on bathing preferences as used by nursing care homes (cf. Bartoszek, 2014; Barrick, Rader & Sloane, 2003). In addition, the interview guidelines were reviewed by the project partners and then validated in the context of primary and secondary user pre-tests. Both interview guidelines (cf. Figure 3-4) start with basic information on the interview conditions and demographic information on the interviewee. The primary user interview guideline is structured into five parts: health, showering habits (current situation), showering habits (desired situation), questions about an intelligent showering system based on images, and questions about the presented prototype/mockup and alternative materials for the shower hose. The expert interview guideline was structured into four parts: questions on body hygiene of the primary users, evaluation with respect to the intelligent showering I-SUPPORT system, questions on the prototype and materials, and questions on acceptance.
3.2.7 Interviewing process Depending on the interviewee’s wishes, the interviews were held either in the Independent Living Centre at FRA-UAS, at the expert’s facility or at the interviewee’s home. Figure 3-4 provides a detailed overview of the complete interview process. After the greetings, the interviewee was provided with basic information about the I-SUPPORT project (cf. App. A). Then the informed consent was read aloud to the interviewee. After the informed consent was signed, the interview started with questions on the demographic situation of the interviewee. In the course of the interview, the interviewees were provided with more information on the I-SUPPORT project, especially the technology of the shower arms (soft
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 75 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
robots/octopus-project), first pictures of the mockup, followed by the presentation of the model of the gripper arm (cf. Figure 3-2), and the alternative materials for the shower hose (cf. Figure 3-3). The interview guide consisted of closed, open and multiple choice questions. Interviewees were encouraged to answer the questions open and freely and add further important aspects. All interviewees were asked whether a picture of their bathroom could be taken in order to compile a documentation of typical bathroom (standard) situations in Germany among private households and nursing care homes. The interviews ended with information on planned focus groups and an invitation to participate in those. Primary user interviewees received a natural sponge as “Thank you” and secondary user expert interviewees were given a book on the “Future Bath”.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 76 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 3-4. Description of the I-SUPPORT interview procedures, cf. App. A to E.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 77 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
3.3 Results
3.3.1 Primary users’ health and problems Most common diseases reported bythe interviewed elderly were high blood pressure, cardiovascular diseases, and arthrosis. Others include diabetes, Parkinson’s disease, Scoliosis, Osteoporosis, and Cataract (see Figure 3-5). Additionally, ten of the users reported to have an approved degree of disability. Severity ranges from 50 to 100.
High blood pressure 9 Cardiovascular diseases 5 Other physical limitations 4 Arthrosis 4 Allergies 2 Parkinson's Disease 2 Diabetes 2 Rheumatism 1 Endoprosthesis (Knees) 1 Cataract 1 Restless Leg Syndrom 1 Osteoporosis 1 Scoliosis 1 Soft-tissue rheumatism 1 Psychological diseases 1
0 5 10 15 20 25 30
Figure 3-5. Chronic diseases as reported by primary users. (N=30)
Sensory and mobility abilities are important for the operation and transfer procedures with the I- SUPPORT product. The huge majority, i.e. 27 primary users, reported to need glasses, and five also needed hearing aids. Mobility was limited in nine of the 30 users. Three of them reported to use a cane or a walking frame, and one is a wheelchair user.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 78 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
The skin was mostly reported to be dry and/or sensitive. Some of the primary users reported irritated, cracked, and oily skin (see Figure 3-6).
a lot a bit not
1 irritated 4 25 5 sensitive 8 17 1 cracked 3 26 3 oily 0 27 5 dry 19 6
0 5 10 15 20 25 30
Figure 3-6. The skin status as reported by the primary users (N=30).
About half of the primary users reported pain sensitive body areas. This is especially interesting with respect to the interaction of the robot with the skin of the user. Figure 3-7 shows the sensitive body areas on the left and non-reachable body regions on the right. The size of the circles is determined by the frequency of primary users’ indications. The bigger the size of the circle, the more often it was mentioned by the users. Knees, back, hips and feet were most often reported as being sensitive regions. The most outstanding non-reachable body region is the back. Fourteen interviewees reported problems or not being able to wash their back without assistance. Second problematic areas are the feet, where ten interviewees had problems to wash when showering. Other problems mentioned were reaching the head and the private parts (genitals and buttocks) as well as the legs. These findings are congruent to the reports of the secondary users. In their opinion, particularly difficult body parts are the head, the back, the private parts (especially the buttocks), legs, and feet; especially the sole of the feet (cf. Figure 3-7). In addition, skin folds can be a problem particularly for obese users.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 79 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Front Back Front Back
Figure 3-7. Overview of pain sensitive body parts on the left and non-reachable body regions on the right. The size of circles is based on the frequency of primary users’ indications (N=30).
As reported by the secondary users, the support provided in nursing care facilities is very individual depending on the abilities of the person needing support for showering. It starts with ensuring a comfortable room temperature and the preposition of needed utensils, such as washing lotion, towels and fresh clothes. Next is the transfer to the bathroom and undressing the patient if needed. Before showering, going to the toilet is an important issue. Here also, support has to be provided. In the following the showering process as disclosed by the secondary users will be presented. The actual showering process starts with the transfer into the shower and unto the showering stool as well as finding the right water temperature. A pre-setting is usually made by the carer and is then carefully tested either at the limbs or hands of the patient. Washing support depends highly on the resources of the person in need of care, i.e. the patient is encouraged to wash those parts him/herself that he/she is able to. Support is given individually where needed; this can be e.g. guiding the patient’s hand. A very important aspect during the whole procedure is communication. The carer asks the patient what he/she wants to do and how it should be done on the one side; and on the other side gives constant feedback on her/his actions in order to include the patient as much as possible.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 80 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
After showering, the patient is usually transferred into a dry area of the bathroom, where she/he is towelled. This is also done to reduce the risk of slipping. Other actions that might need support include putting on lotion, dressing, as well as drying and doing the hair. The main fear among the elderly as reported by the secondary users is to slip and fall. This fear is even increased by the thought of lying on the floor and not being able to get help when being home alone. Also they might be afraid that the water is too hot. This is especially due to the fact that they might not be able to sense the water temperature right or react in a suitable manner. Other fears include becoming cold during the showering process, being exposed in front of the carer, and getting water above the head or into the eyes.
3.3.2 Users’ showering habits and situation/equipment When being asked what kind of support for showering they preferred, half of the primary users chose a technical aid. Second favourite is support given by a family member (cf. Figure 3-8).
technical aid
family member
indifferent
professional carer
0 5 10 15 20 25 30
Figure 3-8. An overview of the primary users’ preferred support for taking a shower (N=26).
One part of the questionnaires was about the primary users’ showering habits. About half of them claimed to shower daily. Next frequent was three times a week. Most of the primary users take a shower in the morning, about one third showers in the evening. Two thirds take up to 10 minutes for the shower process (cf. Figure 3-9). One out of three interviewees needs only up to five minutes from entering the shower until starting the drying process, and another third finishes this process within 15 minutes respectively. These findings are congruent with findings from an international study conducted by Hansgrohe (2014). Here French people were the fastest with approximately 10 minutes, whereas Chinese people took the longest time with 19 minutes showering. Nearly all of the primary users (28) wash their hair when having a shower.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 81 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
up to 5 minutes 10
5 to 10 minutes 9
10 to 15 minutes 2
15 to 20 minutes 3
20 to 30 minutes 5
0 5 10 15 20 25 30
Figure 3-9. Shower duration as reported by the primary users (N=29).
The main reason for taking a shower is cleanliness. However, wellness and refreshment play also very important roles. In addition, some primary users reported the use of a hot shower to relieve e.g. back pain. When it comes to the preferred kind of water jet, about half of the users chose the “raining water jet”; next was the “standard water jet”. Others were a “massage water jet” or a water jet with extra high water pressure.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 82 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Massage jet Standard water jet
Raining water jet Extra high water pressure
Figure 3-10. Overview of different kinds of water jets (cf. GROHE 2015)
Another important aspect for the I-SUPPORT system requirements are the utensils used during the showering process. Here, a variety of different strategies can be observed. Above two-thirds of the interviewees reported the use of shower gel for washing their body. Though, the other third reported to use soap instead and in addition to that, five of all users reported to use a second shower gel, e.g. for the private parts. Figure 3-11 shows that more than a quarter of the interviewees reported to use only their hands for washing themselves. Others use a variety of utensils, including washing cloth, brush and sponge. Nearly a third claimed to use more than one utensil when taking a shower. Most utensils are stored within the showering cabin: standing on a shower caddy, on the edge of the shower or bathtub, or hanging at the wall.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 83 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
hands only 8
washcloth 7
brush 7
Kese, turkish washcloth 5
sponge 4
others 2
use of more than one utensil 9
0 5 10 15 20 25 30
Figure 3-11. Overview of the utensils used during the showering process (N=30).
For drying purposes all primary users reported the use of a towel, for drying the hair 12 users used a hair dryer in addition. Also, more than two-thirds of the interviewees reported to put on lotion after having a shower, two of them needed a special medical lotion. The ambience/atmosphere should be also taken into consideration. Two thirds of the primary users claimed to prefer a special odour when taking a shower and a third likes listening to music. Preferred lighting conditions are rather diverse. Some like bright, some dimmed light. However, most prefer warm and natural light in general. Figure 3-12 gives an overview of safety relevant equipment that is either available in the users’ bathrooms or desired by the users. The equipment standards differ. Handrails are the most common in the bathroom, and about half of the users possess some kind of showering stool and another third of them would like to have one. Especially with respect to accessible design, there is a gap between those users that have it and those that desire it. Also noticeable – but in line with research results (Klein et al., 2015) - is the small number of personal alarm systems compared to the other technical equipment. These findings are congruent with the primary users’ wishes when asked for the perfect shower. The most important wish is a large, accessible design with a non-slip floor. The shower should have either a very big door or none at all. According to the primary users not having a shower door is the most preferable due to multi-tasking problems when opening the door or curtain of the shower. Especially if people are very frail they need all their cognitive for balance, posture and perception. Opening shower doors and moving into the shower might result in falls where often the reason is not recognized.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 84 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
available desired
handrails 20 5
showering stool 16 11
accessible design 9 16
non-slip floor 7 12
personal alarm 6 8
0 5 10 15 20 25 30
Figure 3-12. An overview of security relevant equipment that is available or desired (N=30).
Important for the primary users are handrails within the shower cabin and guiding out of the shower cabin. A showering stool should be installed at the wall and maybe also a footrest for washing the feet. Height-adjustable armatures and shower hose would be very helpful for smaller people. All-in-all it should be easy to use and the temperature should ideally be regulated through sensors that are able to detect whether the user is too hot or cold, but at least there should be a protection against scalding. This is a very important issue, mentioned also by the secondary users. The water flow and pressure should be adjustable. Some of the users like the water coming from all sides, and some dislike water from above; which is also a fear experienced by the secondary users. Since the person showering is forced to close her/his eyes in order to avoid the water, the balance will be further impaired and the fall risk increases. Another crucial point as mentioned by secondary users is the available shelf space. It should be sufficient for all needed accessories and tools and in such a position that it is easy reachable. In a study from 2012 on showering habits in Germany the top three features of the perfect bathroom that were named were “easy-to-clean”, “practical and functional design” and “age appropriate equipment” (VDS, 2012). However, most standard bathrooms have a lot of building constraint which are due to the small size (average size of German bathrooms in 2012 was 7.8 m2, and 28% were even only 6m2 (VDS, 2012). The building layout prevents establishing large accessible shower cabins as described above.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 85 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 3-13. Pictures of bathrooms encountered during the interviews.
Most residential buildings (89.5% in Germany; Zensus, 2011) are built 1999 or earlier. Only 5.2% of examined apartments (N=962) were accessible. 83.2% of the apartments had some barriers, whereas 11.6% had extreme barriers. Until 2025 more than 2 million apartments will need rebuilding under accessible considerations (BMVBS, 2011). Some limitations regarding a complete accessible design of the bathroom exist. The height of the floor in the bathroom must be large enough to ensure enough gradient within the pipe, to make sure the water can drain off correctly. If this is not the case, the shower tray must be at least five to eight cm high, so that a completely accessible design is not achievable. 3.3.3 Religious and cultural differences regarding the showering process Looking at differences in washing with respect to religion, differences were found in Muslim religion, as stated by primary interviewees with a Muslim background. People with Islamic beliefs are required to wash themselves five times a day before prayer. This includes washing hands/arms, head and feet, but is not performed under a shower and has therefore no impact on the showering system. However, some secondary users mentioned it to be important for Muslims that the water is constantly flowing when washing themselves. The largest cultural difference that could be found was in Japanese bathing traditions. The two Japanese interviewees reported that Japanese people usually take a hot bath in the evening. They first wash themselves thoroughly before taking a relaxing and warming bath. Showering is usually done with a shower hose within the bathroom. Some kind of shower cabin or curtain is not installed.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 86 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
One interviewee who lived in India until adolescence reported that in India it is not the showering procedure that differs from European habits, but the frequency. Since it is very important not to have any body odour, people may take a shower several times a day.
3.3.4 Opinions on the I-SUPPORT concept, first impressions, and materials Within the scope of the Design Thinking Method a very early feedback on the shower concept was aimed for. The questionnaire dedicated Part II to IV in an iterative approach. In the first instance pictures and videos of the I-SUPPORT system were presented and the first question was whether the interviewee would use such a product. From the primary users, 22 approved this idea and eight of the secondary users. Another three claimed that they would at least try it, further usage will then depend on the experiences made. One would try it, but not use the system; another one would not try it at all. The remaining two secondary users were not asked this question, because in their job description washing people was not included. Nearly half of the primary users responded in a positive way, when being asked for the expected perception during the showering process with the help of the I-SUPPORT system. About one fourth of the users said it would require getting used to. Other answers were “it depends” and “not able to evaluate before having tested it”. Only three of the primary users expected negative feelings during the washing process with the I-SUPPORT system (cf. Figure 3-14).
Positive 13 Requires getting used to 8 Not able to evaluate before having tried… 4 Depends 1 Negative 3
0 5 10 15 20 25 30
Figure 3-14. The overview shows the primary users' answers with regard to the expected showering sensation with the I-SUPPORT system (N=29).
The reactions on the mock-up shower arm were rather inspiring trust/confidence and less frightening. Only six of the primary and one of the secondary users found that the mock-up shower arm did not inspire trust/confidence at all, whereas 15 of the primary users found it a bit trustworthy/confiding, 8 strong and one very strong confiding. Five of the secondary users found it a bit trustworthy/confiding, three strong and two very strong trustworthy/confiding. 20 primary and three secondary users thought that the mock-up shower arm was not at all frightening. Eight primary and four secondary users found it a bit frightening, whereas two primary and four
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 87 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
secondary users found it strongly frightening. None of the interviewees found the mock-up shower arm very strongly frightening. Primary and secondary users were asked to choose three favourites on the presented materials for the shower arm out of 15 examples as Figure 3-15 shows.
Figure 3-15. Materials. The preferences were very diverse therefore no pattern could be established. Table 3-2 shows the materials chosen, arranged according to (a) how often a primary or secondary user chose this material as the most preferable, and (b) how often these materials were chosen as a whole, i.e. including second and third preferences of the users.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 88 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 3-2. Ranking of the primary and secondary users’ most preferred materials. On the left only those materials that are preferred as a first choice are listed. On the right side, all materials that were named are listed, i.e. also second and third choices (N=43). First preference All preferences Frequency Material Frequency Material 11 E 20 E 5 G 14 O 4 I, J, O 11 L 3 F, N 10 I 2 C, D, L 9 G 1 B 8 A, F, J, N 6 C 5 D, K 3 B 2 M 1 H
When compared, the choices of the primary and secondary users show some similarities, but also differences (cf. Table 3-3 and Table 3-4). However, both of them chose the material “E” most often. This is a soft coloured fabric that resembles e.g. the touch of a softball. Also in the top five for all indications are the materials “G”, “O”, and “L”. Material “G” is a rather simple plastic hose. The materials “O” and “L” are very similar. They are tubes made out of a woven plastic fabric. Apart from the materials above, the opinions can be quite diverse. For example materials “F” – a soft silicon tube – is second in the overall preferences named by the secondary users.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 89 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 3-3. Ranking of the primary users’ most preferred materials. On the left only those materials that are preferred as a first choice are listed. On the right side, all materials that were named are listed, i.e. also second and third choices (N=28). First preference All preferences Frequency Material Frequency Material 7 E 11 E, O 5 G 9 L 3 N 8 A 2 C, D, I, J, L 7 G, N 1 B, F, O 6 I 5 J 4 C 3 F, K 2 D, M 1 B, H
Table 3-4. Ranking of the secondary users’ most preferred materials. On the left only those materials that are preferred as a first choice are listed. On the right side, all materials that were named are listed, i.e. also second and third choices (N=15). First preference All preferences Frequency Material Frequency Material 4 E 9 E 3 O 5 F 2 I, J, F 4 I 3 D, J, O 2 G, C, L, B, K 1 N
Especially within the group of secondary users the opinions about the preferred materials and tools were rather different. Hygiene is a key issue. The I-SUPPORT system must be easy to clean, to disinfect and to change. Where the system is used by multiple users, the tools have to be changed after every usage/user. The materials should not smell of latex and a latex-free product
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Horizon 2020 ICT-Supported Bath Robots
might be advantageous (e.g. because of allergies). Another important issue is washing between toes, skin folds and alike. For this not only a special design is needed, skin folds etc. have also to be lifted with the second hand during the showering process, in order to clean those parts. One part of the interviews was about suggested functionalities of the I-SUPPORT system. The aim was to find out, what functions would be necessary or helpful from the perspective of the secondary and primary users. The secondary users’ answers can be roughly divided into four different categories, namely body hygiene, design of the system, wellness functionalities, and security aspects. The findings presented in the following paragraphs are based on statements made by secondary users, if not stated otherwise. The first category is “body hygiene”. The system must be able to clean the user in a sufficient way. The washing process should be comparable to the washing process performed by a human. A footbath was judged as being helpful for soaking the feet before cleaning them. The second category entails answers on “the general design of the system”, like movement etc. It was suggested that the user would probably feel more comfortable when sitting with his/her back to the wall and without moving. This is due to the fact that moving always means more instability and thus insecurity for frail persons. The suggestion was that instead of the user the system should move. Apart from that, the system should be very flexible with respect to the different body parts of the user, but also with respect to the preferences of different users. The system should also be sensitive according to the requirements of the different body parts. The back can be scrubbed eagerly, whereas the spaces between the toes require very sensitive handling. In addition the system should be able to hold different objects, like the shampoo, a towel or a sponge. Secondary users agreed that an intuitive operation of the system is an absolute must. The system should not only be controllable by voice command but also be able to respond by voice/speech. However, support during washing might be among the elderly one of rare opportunities for communication during the day. Secondary users indicated that the system should be able to simulate this emotional psycho-social support. Voice/speech could also be used in order to give instructions and feedback to the user. From the perspective of the user it would be desirable that the I-SUPPORT system is able to establish communicated proximity between the user and the system. Apart from that , there should be at least an alternative interface, which is also easy and intuitive to use. This could be implemented on a relatively big touch display, e.g. a tablet as suggested by some of the secondary users. The third category included answers on “wellness functionalities”. Both, primary and secondary users find the feeling of relaxation and wellbeing during the showering process extremely important. Therefore the system should be able to establish a pleasant atmosphere. The shower hose might be able to simulate a rain jet (cf. Figure 3-10), which was wished by several interviewees. The fourth category entailed answers on “security aspects”. The system should be secure in itself. There has to be a kill switch/emergency stop. Injuries of any kind must be avoided at all costs. Therefore it is necessary that the system can always find the optimal water temperature.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 91 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Also mentioned by secondary users, fluctuations in water temperature and pressure due to pressure variations within the pipes have to be avoided. The risk of falling must be regarded as well. For minimizing the risk of falling, the system should simplify or take over the transfer into the shower. The system should also be able to stabilise the body of the user at any time. Questions on security aspects of the I-SUPPORT system were multiple-choice. Figure 3-16 presents an overview of the answers of the primary users regarding basic system functionality. All of the users thought fall detection to be very important for the system (one user did not answer this question). The importance of a personal alarm and an automatic emergency stop of the system were rated quite similar. Only the functionality of grabbing and holding objects resp. grabbing objects from the floor were seen as redundant by some of the users.
unimportant important
Grab and hold objects 5 24
Emergency stop 2 27
Personal alarm 1 28
Grab objects from the floor 8 21
Fall Detection 29
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Figure 3-16. Features from the I-SUPPORT system, rated by the primary users as important or not important (N=29).
In a next step, the interviewees were asked how helpful they find some of the I-SUPPORT system core functionalities. Figure 3-16 presents the answers of primary and Figure 3-17 the answers of the secondary users. The large majority found an adjustable water pressure helpful, only one primary and none of the secondary users found this option to be not helpful at all. The functions “soaping” and “handing a towel” seem to be also rather helpful. Two thirds of the interviewees found them helpful. The drying function of the system was rated the least helpful functionality of the I-SUPPORT system. Though, half of the primary and secondary users found it to be helpful and a third of the primary users at least partly helpful.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 92 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
not helpful less helpful partly helpful helpful
Adjustable water pressure
Soaping
Hand a towel
Drying function
0 5 10 15 20 25 30
Figure 3-17. Features from the I-SUPPORT system, rated by the primary users as helpful, partly helpful, less helpful and not helpful (N=29).
not helpful less helpful partly helfpful helpful
Adjustable water pressure
Soaping
Hand a towel
Drying function
-1 1 3 5 7 9 11 13 15
Figure 3-18. Features of the I-SUPPORT system, rated by the secondary users as helpful, partly helpful, less helpful and not helpful (N=15).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 93 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
About two thirds of the primary users thought it good or important that the system is customizable according to the wishes of the customer: e.g. the colour and material of the I-SUPPORT system shower arm. Four of the primary users were indifferent about this aspect and five of the users found individualisation to be unnecessary or negative. Eleven of the primary users were also asked this question. Ten of them found the idea important and one was indifferent regarding individualisation. Regarding a preferred colour of the I-SUPPORT system analysis showed that there are diverse preferences among the interviewees. However, light colours such as a light blue or the colour the current mockup of the gripper arm is designed were described as symbolizing hygiene and judged rather positive, by some of the primary and secondary users. In contrast the feeling of the material was often described as disgusting, creepy or odd/uncommon by primary and secondary users. Only those primary users that already had experience with similar materials, e.g. from a breast prosthesis or work within the health-care sector appraised the material as positive. Figure 3-19 shows an overview of the possible target audience as suggested by the primary and secondary users. Most interviewees emphasized physical constraints in general rather than the age of the possible user groups.
Primary Users Secondary Users
17 People with physical constraints 6 5 Elderly people 3 People with difficulties regarding washing 2 For everyone 2 For myself 2 I don't know 2 People considering remodeling their bath 1
People with own household 1 0 5 10 15 20 25 30
Figure 3-19. Possible target groups of I-SUPPORT as suggested by primary and secondary users (N=45).
3.3.5 Acceptance Acceptance is a very important topic with respect to the use of robots/new technologies. Elderly are often viewed to be more reluctant than younger people. The interviewed secondary users
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Horizon 2020 ICT-Supported Bath Robots
were all but one rather positive about the I-SUPPORT idea. On the question of how other potential secondary users might think about such a system, the answers were more concerned. It was assumed that others might be sceptical because of the idea of an automatic “car wash” for elderly and the automation of body hygiene. Also there might be a fear of becoming superfluous and losing the employment. It might feel disconcerting that a robotic system takes over carers’ tasks; especially work that is done with pleasure and that includes important interpersonal aspects. The washing process might be one of the last opportunities for the elderly where they have body contact with another human. Besides, due to time constraints, it is often the only care process that enables communication between carer and patient. Additionally was mentioned that the use of a robot might not be conform to the concept that people should use their own resources and perform activities they are able to do as long as possible, i.e. washing their face and other reachable body parts or holding a wash cloth and the carer supports guiding the patients hand. Several factors can influence the acceptance of the I-SUPPORT system. A general factor that is very important for primary and secondary users is the system safety and security. Especially secondary users state that the system should fulfil very high safety and security standards, so that injuries e.g. due to malfunctioning of the system will be avoided. Apart from that the system should look safe and secure, so that the users feel safe and secure when using the system. A similar aspect is the reliability of the system. In the opinion of the secondary users, the I- SUPPORT product should be well developed so that breakdowns of the system during operation do not happen. This was also very important for primary users. Other important factors as stated by primary and secondary users are design and ergonomics. These two are related to each other. The system should have an aesthetic appearance. All sensory organs should be addressed, i.e. the materials should also have a nice smell and good touch/feeling. The system should have an ergonomic design regarding the interface and the whole system. These components were judged vital for acceptance, especially by the secondary users. One secondary user claimed that the introduction of the I-SUPPORT system should be accompanied by an ethical discourse and induction training. Before using the system, an adequate training for users was seen as essential. Primary users have to be trained as well and in addition should feel pleasant when using the system and gain independence through the use. These findings are congruent to the aspects in Table 3-5. It shows the summarized answers to the questions what aspects the I-SUPPORT system must fulfil regarding design, ergonomics, security and reliability as reported by secondary users.
Table 3-5. Aspects the I-SUPPORT system must fulfil regarding design, ergonomics, security and reliability as reported by secondary users. Primary users Secondary users Design System must be well designed with an Design is less important. appealing exterior. The design should be expressive, i.e. the
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Horizon 2020 ICT-Supported Bath Robots
task of the system must be clear by looking at it. Design options, e.g. for colour and materials, are desirable. Safety and The system must be safe itself and must Safety and security are very important Security the user give a safe and secure feeling. for the user’s family and even more important for professional carers. Injury free operation is an absolute must. Ergonomics The interaction with the system should The system must be easy to use. be intuitive. Automatic or pre-defined settings for Ergonomic construction, i.e. suitable for different users would be helpful. all sizes/strengths /people. An ergonomic construction, i.e. construction under anthropological aspects is even more important due to the fact that it should be usable for every resident of e.g. nursing care facilities. Reliability The system must be highly reliable, i.e. The system must be highly reliable, i.e. no breakdowns during operation. no breakdowns during operation. Easy cleaning and maintenance. Easy cleaning and maintenance.
3.4 Discussion 3.4.1 Derived user requirements User requirements can be divided into functional needs, i.e. what a user should be able to do with the system and product qualities, i.e. several attributes of the system such as safety, security and reliability. The most important function of the I-SUPPORT system is to clean the user. Especially those body parts that are hard to reach should be washable by the system i.e. the private parts and the buttock, the lower extremities including the bottom of the feet and the space in between the toes, as well as skin folds. Also helpful would be the possibility to clean the ears and to wash the hair. Since most interviewees claimed to wash their hair under the shower, it should be at least possible to perform this task manually, even though the I-SUPPORT system is installed and does not provide this feature. During the showering process communication between the user and the system is essential, as stated by the secondary users. The user should be able to guide the system and the system must inform the user on its actions and give general feedback. This might prevent insecurities and confusion, making the system more predictable.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 96 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Also stated by the secondary users was, that the system should not solely be able to wash the user independently, but also support him/her in doing so as a carer would do. It is vital to encourage patients or frail persons to keep up their resources and perform as many tasks as possible independently or supported in order to sustain physical and mental abilities. Therefore it would be counterproductive if the I-SUPPORT system functions and performs the washing tasks without considering the users’ resources. In addition the system should be able to adapt to the preferences of each user. Two thirds of the interviewees reported to need five to fifteen minutes for the showering process. Therefore, the I-SUPPORT system should be within this time scale for performing washing tasks. After the shower the user must be able to dry him/herself. This should be at least supported by the system. A frail person in need of the I-SUPPORT system in order to be able to take a shower faces probably also problems with the drying process, e.g. he/she might not be able to reach the lower extremities for drying purposes. Since elderly people often have sensitive skin the system should be able to detect different skin regions and patterns, especially impaired skin regions. Additionally, the systems’ touch/force sensibility should not be limited to the arms of the system, but should also take into account the water pressure which should be adjustable depending on the body region. Other functional needs include the use of different kind of utensils for cleaning (e.g. sponge, wash cloth), the ability to use a preferred cleansing lotion (i.e. soap, shower gel), the function of grabbing and holding objects, as well as height-adjustable armatures and shower hoses. Apart from washing, it might be helpful if the system was able to help also with drying and putting on lotion. People not being able to reach their feet for washing might have also difficulty with drying them properly or putting on lotion. Primary users would like enough space within the shower, even to bend down easily; as well as a big opening with handrails leading out the shower space. Also, they suggested shelf space to have enough storage opportunities for all needed utilities like shampoo and soap. In addition some wellness functionalities were asked for, e.g. an automatic regulation of the room temperature and of the water itself, but also adjustable water flow including water pouring from all sides but from above, a soft jet and massage functions were mentioned. One part of the product qualities is the system’s safety and security. This was highlighted by the primary and secondary users. From the findings in section 3.3 it can be concluded that a non-slip floor combined with an implementation of some kind of fall detection system and an automatic emergency stop are essential features. Also preferable features for fall prevention are handrails and the help with the transfer into and out of the shower as well as a sit-to-stand and stand-to-sit transfer. The system should be able to support the user in general. It was also mentioned that the shower should be accessible and have no curtain or doors, but a plain opening. This is due to the dual tasking problem that occurs when the user wants to open the door/curtain. In this situation the task of opening the door requires too many resources that are no longer available for controlling posture and movement.
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Horizon 2020 ICT-Supported Bath Robots
A personal alarm is equally important. It should trigger automatically, e.g. if the user falls and does not move; but there should be also the possibility to trigger it manually. This applies also to the emergency stop. In order to prevent burnings from hot water, some kind of thermostat armature is essential. Also it must be ensured that the user is kept warm during the complete washing process, even if the system is washing the feet, the rest of the user’s body must be kept warm as well. The acceptance of the product by the users is also a product quality. One important point that kept being mentioned was cleaning and maintenance of the system. These two must be very easy, not time consuming, and preferably not necessary. Further, the system should be easy to use and have good ergonomics. The user must get a feeling of control over the system. It should be based on very mature technology, be safe, secure and reliable. Preferable the system will be able to promote the user’s autonomy and resources, as a professional carer would do. The system should be individually adjustable and have attractive optics. All in all, the user should be enthralled using this product.
3.4.2 Special concerns Secondary users mentioned three major concerns. The first concern relates to the principle of activating care. Frail persons who require support for washing themselves are encouraged to perform those activities they are able to, e.g. washing their face or upper limbs. Professional carers might support by guiding the patient’s hand during the washing process. This procedure is undertaken in order to maintain existing functionalities in the frail person. Secondary user thought it an essential feature a technical system should have. Otherwise the technical support contributes to loss of functionalities and consequently increased need of care in other activities and loss of independence. A second concern is the omission of communication between carer and elderly person. Social isolation is a huge problem among frail elderly persons. A professional carer from an ambulatory/domiciliary service might be one of few opportunities for communication, intimacy, and body contact. This bears relation to the last point of concern. The washing process is a good opportunity for the professional carer to screen for skin problems on a regular basis. Especially elderly people often have a sensitive and dry skin that might need special care, also decubitus might occur. The showering process allows the professional carer to detect such problems without a special appointment, were the frail person might be even more uncomfortable due to an unfamiliar procedure. These three concerns are worth considering for the final system. They are an essential part of the care process and should not be skipped.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 98 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
References Barrick, A. L., Rader, J. & Sloane, P. (2003). Bathing without a battle. University of North Carolina at Chapel Hill. Bartoszek, G. (2014). PflegeWissen – Körperpflege. Elsevier, Urban & Fischer. BMVBS (2011). Forschungen Heft 147 – Wohnen im Alter. Berlin. Available at http://www.bbsr.bund.de/BBSR/DE/Veroeffentlichungen/BMVBS/Forschungen/2011/Heft147 _DL.pdf;jsessionid=36FD13744F0B160C8AFB10B6D36F3A57.live2052?__blob=publication File&v=2 (last accessed at 20.10.2015). Claßen, C. (2012). Zur Psychologie von Technikakzeptanz im höheren Lebensalter: Die Rolle von Technikgenerationen. Dissertation. Heidelberg. Gürtler, J. & Meyer, J. (2013). 30 Minuten Design Thinking. Offenbach: Gabal-Verlag. GROHE Deutschland Vertriebs GmbH (2015). Entdecken Sie die einzigartigen Duschstrahlarten der GROHE Brausen. Available at http://www.grohe.de/de_de/badezimmer/strahlarten.html (last accessed at 31.10.2015) Hansgrohe (2014): Hansgrohe Studie zeigt: Die Deutschen sind die Schnellsten im Bad. Press briefing available at www.hansgrohe.de/23001.htm (last accessed at 12.10.2015). Klein, B., Reutzel, S. & Roßberg, H. (2015). Zur Mediatisierung assistiver Technologien – der Hausnotruf als Kommunikationsmedium für ältere Menschen. In: Kutscher, N., Ley, T., Seelmeyer, U. (ed.), Mediatisierung (in) der Sozialen Arbeit. Baltmannsweiler: Schneider Verlag Hohengehren. Plattner, H., Meinel, C., & Leifer, L. (ed.). (2014 ). Design Thinking Research. Springer. Vereinigung Deutsche Sanitärwirtschaft e.V. (VDS). (2012). GfK-Badstudie: Erhellende Einblicke. Press briefing available at www.sanitaerwirtschaft.de/de/presse/2012/gfk_badstudie_ erhellende_einblicke-228.aspx (last accessed at 12.10.2015). Zensus (2011). Gebäude und Wohnungsbestand in Deutschland. Statistische Ämter des Bundes und der Länder. ZVHSK Zentralverband Sanitär Heizung Klima & Zebner, F. G. (ed). Bad der Zukunft/Future Bath.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 99 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
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Appendix A Short project information
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 100 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
B informed consent
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 101 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 102 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
C primary user questionnaire
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 103 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 104 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 105 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 106 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 107 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 108 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 109 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 110 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 111 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 112 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 113 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 114 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 115 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 116 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 117 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 118 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 119 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 120 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 121 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 122 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
D Secondary user questionnaire
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 123 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 124 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 125 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 126 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 127 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 128 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 129 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 130 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 131 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 132 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 133 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 134 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 135 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 136 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 137 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 138 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 139 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 140 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 141 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
E Extra material used for primary user questionnaires
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 142 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 143 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 144 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 145 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 146 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 147 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 148 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 149 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
4 Use cases and system functionalities Authors: Dr. Jochen Werle, Prof. Dr. Klaus Hauer (Bethanien), Prof. Dr. Costas Tzafestas, Dr. Xanthi Papageorgiou, Nancy Zlatintsi (ICCS), Prof. Angelo Sabatini, Vincenzo Genovese PhD (SSSA), Dr. Panagiotis Vartholomeos (Omega)
4.1 Introduction (Bethanien) Use cases represent typical scenarios for the design of AAL devices to guide technical development and to allow validation of assistive technologies. For the development of the I- Support bath robot system we defined different use case scenarios from a clinical perspective, based on a comprehensive model of impairments, limitations and user requirements of a geriatric population (see Chapter 2 of D 1.1). The proposed use case scenarios take into account the specifications, mentioned in the project application. The I-Support modular service robot system includes three service robotic devices (see Figure 4-1): a motorized shower chair for supporting stand-to-sit and sit-to-stand transfer as well as the transition into/out of the shower area, a robotic shower hose, dedicated to the provision of pouring water and soaping functionality, a robotic washer/wiper, providing the scrubbing, wiping and drying functionality.
Figure 4-1. Initial set-up of the I-Support robotic devices .
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 150 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
During the course of the project, the feasibility to have only one soft robotic arm serving both, the shower hose functionality and the washing/wiping tasks, will be investigated. This also applies for the drying functionality: The consortium has to take the decision, whether drying is realized with a cloth or with hot air stream. In the description of the use cases of the shower process, at this time we currently assumed that the drying functionality is carried out with a cloth. Washing the head is deliberately excluded from the I-Support washing tasks, because it is the only part of the body, for which a robotic device has been developed and soon will be commercially available. Otherwise, the I-Support is open to adaptations. In a future step, a hair-washing functionality could be integrated, e.g. with an end effector, useful for washing the hair.
4.2 Initial use case scenarios and use cases (Bethanien) Initial use cases describe, at a higher level of abstraction, the user-robot interaction. They are descriptive, represent only the "what the system should do" and include all possible scenarios based on the impairment model as presented in the previous chapter of this report. Within the development process of the I-Support bath robot system, we define a hierarchy of system processes, representing core functionalities and additional support or optional functionalities to be integrated in use case scenarios of the I-Support project. Processes can be divided in several sub-processes or use case scenarios. In Table 1-1 we present a list of use case scenarios and associated use cases.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 151 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-1. I-Support system: Core process, support and optional processes Core process – Transferring and showering Sub-processes / Use case scenarios Processing steps / Use cases Stand-to-sit transfer/transition outside-inside 1 – 6 Core region shower process 7 – 16 Distal region shower process 17 – 25 Back region shower process 26 – 34 Posterior region shower process 35 – 46 Transition inside-outside/sit-to-stand transfer 47 – 53 Support process – Operation, control and modification of system functionalities Sub-processes / Use case scenarios Processing steps / Use cases Operation and control of system functionalities, e.g. base settings, 54 verbal instructions etc. Subsequent modification of base settings, e.g. water temperature, 55 – 56 pressure of water jet
Emergency procedures, e.g. fall detection, prolonged state of 57 inactivity
Visual control, e.g. operation and control of system functionalities 58 with visual impairment
Human-Robot communication, e.g. for user with hearing 59 impairment Optional process – Skin care Sub-processes / Use case scenarios Processing steps / Use cases Skin care 60 – 64 Skin inspection 65 – 67
In Table 4-1, we have listed the various sub-processes according to our definition of a hierarchical structure. Within the core process, we describe each use case scenarios in order of the overall sequence of a shower process from entering the bathroom until leaving the shower zone. The use case scenarios of the support process have no structural order. They describe technical requirements, which from a clinical perspective, might be relevant for potential users, especially with impaired cognitive and/or sensorial functions. The optional process has a clinical significance, but is not mentioned in the project application. In the right column, we have assigned the relevant use cases. They are described in more detail in the following tables.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 152 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
The core process of the I-Support project is the entire shower process. For the shower process we defined four use case scenarios for different body parts, based on various user requirements (especially motor impairments and limitations), with a range from assisting (use case scenario core region shower process) to fully automatic functionalities (use case scenarios distal, back and posterior region shower process). Each shower process is starting in a sitting position within the shower area to facilitate the validation of sub-processes. Because bathrooms have been identified as a hazardous location with a high prevalence of fall- related injuries, we suggest to integrate the transfer and transition use case scenarios to the core process. The support processes comprise functionalities for the overall operation, control and modification of the I-Support bath robot system with respect to cognitive, sensorial, and motor impairments of the potential user group (see Chapter 2 of D 1.1). They still need to be specified by technical partners. The optional process describes two valuable functionalities for skin care. In the tables below, we describe the use case scenarios and associated use cases in detail.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 153 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-2. Core process: Stand-to-sit transfer and transition outside-inside No. Use cases Description / Background User requirements / Technical implementation 1 User is entering the In this moment, her/his intention Detection of the user´s bathroom. is unclear. movement; adjustment of the motorized chair. 2 User is starting In this moment, the intention is Detection of the user´s undressing clear. The user is undressing, movement. herself/himself. because she/he wants to wash herself/himself. 3 User is approaching The user is in a standing Motorized chair is adjusted the motorized shower position in front of the motorized based on the user´s profile. chair. chair. She/he wants to have a shower and needs assistance for stand-to-sit transfer. 4a User is sitting down Independent user will have less Motorized chair is performing slowly. problems to sit down; they can the stand-to-sit transfer turn backside to the chair, grip (adjustment in height the armrests and sit down. necessary). 4b User is sitting down More impaired persons have to Motorized chair is performing slowly. learn to turn their walking frame the stand-to-sit transfer and fix it. Then, they grip the (adjustment in height armrest of the motorized chair necessary). one hand after the other, turn backside and sit down. 5 User is standing his If the motorized chair is moving Motorized chair should be feet on the footrest. from outside the shower inside, equipped with a footrest. it is better to have a footrest. Elderly people can´t lift their feet for a long time. 6 User is confirming the When the user feels Motorized chair is moving inside initial position. comfortable, she/he is the shower area and is adjusting confirming the system, that the initial position. Sideward she/he has achieved the starting fixation is essential. position.
The transfer and transition program provides the stand-to-sit transfer and the transition from outside the shower cabin inside. The I-Support bath robot system may provide a functionality for the detection of the user when she/he is entering the bathroom.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 154 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-3. Core process: Core region shower process No. Use cases Description/Background User requirements / Technical implementation 7 User is activating the Inside the shower cabin, the Detection of the user´s position I-Support bath robot user is starting the shower system. process. 8 User is starting the The core region includes all Motorized chair is turning the core region program. body parts, elderly people can front side to the shower system. reach in a sitting position without Shower hose has adjusted in a leaning forward, even with reachable position. limited mobility of joints: Breast, belly, arms, thighs and genitals. 9 User is gripping the He starts rinsing her/his belly, The core region the user can shower hose. breast, thighs, genitals, and wash more or less arms. Right-hander may often independently. The shower hose start on the left side, moving to is smooth. the right. 10 User is stopping the After rinsing the core region, the Shower hose is moving back to rinsing process. user wants to scrub the core the starting position. Shower region. wiper as assistive tool to give the user soap, a cloth or sponge. 11 User is scrubbing the The user is scrubbing her/his Shower hose in stand-by core region. core region by her/his own. modus, reachable. 12 User is stopping the The user wants to place the Shower wiper grabs the scrubbing process. sponge (washcloth) in the washcloth or sponge and moves storage place. it to the storage. 13 User is gripping the She/he starts rinsing again, The shower hose is smooth. shower hose. mostly in the same way as first time. 14 User is stopping the After rinsing the core region, Shower hose is moving back to rinsing process. she/he wants to dry it. the starting position. 15 User is drying the The user is drying the body Shower wiper as assistive tool to core region. parts of the core region by give the user a towel. her/his own. 16 User is finishing the After drying the user wants Shower wiper is grabbing the drying process. place the towel on a storage towel and moves it to the place. storage to get it for the next time.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 155 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
The core region includes all body parts, which elderly people can reach in a sitting position without leaning forward, even with limited mobility of joints: Breast, belly, arms, thighs and genitals. The I-Support bath robot systems may have to provide assistive functionalities: The soft arm shower hose for rinsing with haptic control and a grasping functionality to give the user personal bathing tools, cloth or towel. Table 4-4. Core process: Distal region shower process No. Use cases Description/Background User requirements / Technical implementation 17 User is starting the The distal region program Motorized chair is turning front distal region program. includes the parts of the lower side to the shower system. leg incl. feet, the user can´t reach in a comfortable way (without moving forward, risk of falling). 18 User is activating the The user imitates the movement The shower hose operates fully shower hose. of the shower hose: upside - automatically. down. Inside - outside, backside – front side, foot. A right-hander may often starts with the left side, continuing on the right side. 19 User is stopping the After rinsing lower legs and feet, Shower hose is moving back to rinsing process. the user wants to scrub the the starting position. distal region. Shower wiper as assistive tool takes a washcloth or sponge. 20 User is scrubbing the The user is scrubbing her/his The shower wiper operates fully distal region. distal region by imitating the automatically. scrubbing movements, similar to Shower hose in stand-by the rinsing process. modus. 21 User is stopping the The user wants to place the Shower wiper grabs the scrubbing process. sponge (washcloth) in the washcloth or sponge and storage place. moves it to the storage. 22 User is activating the She/he starts rinsing again the The shower hose operates fully shower hose. distal region, mostly in the same automatically. way as first time.
23 User is stopping the After rinsing the distal region, Shower hose is moving back to rinsing process. she/he wants to dry it. the starting position. Shower wiper as assistive tool to give the user a towel. 24 User is drying the The user is drying the body The shower wiper operates fully distal region. parts of the distal region by automatically. her/his own.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 156 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
25 User is finishing the After drying the distal region, the Shower wiper is grabbing the drying process. user wants place the towel on a towel and moves it to the storage place. storage to get it for the next time.
The distal region program includes the parts of the lower leg including feet. These body parts the user can´t reach without moving forward, which might increase the risk of falling and/or the risk of dizziness when unbending again. The I-Support bath robot system may have to operate fully automatically. The user might be able to control the motions of the soft arms with the remote control through eye contact.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 157 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-5. Core process: Back region shower process No. Use cases Description/Background User requirements / Technical implementation 26 User is starting the The back region program Motorized chair is turning back region program. includes the back from the neck backside/laterally to the shower to the tailbone. The user can´t system. wash the back by herself/himself. 27 User is initiating the While the user props Shower hose is performing shower hose. herself/himself on the armrests, without user´s actions. the shower hose performs the rinsing process of the back automatically. 28 User is stopping the After rinsing, the user wants to Shower hose is moving back to rinsing process. scrub the back region. the starting position. Shower wiper grabs a cloth or sponge. 29 User is scrubbing the While the user props Shower wiper is performing back region. herself/himself on the armrests, motions without user´s actions. the shower wiper performs the The shower-hose is in stand-by scrubbing process of the back mode. automatically. 30 User is stopping the After scrubbing, the user wants Shower wiper is moving back to scrubbing process. to rinse the back region. the starting position. Shower hose is in stand-by. 31 User is initiating the While the user props Shower hose is performing shower hose. herself/himself on the armrests, without user´s actions. the shower hose performs the rinsing process of the back automatically. 32 User is stopping the After rinsing the back region, Shower hose is moving back to rinsing process. she/he wants to dry it. the starting position. Shower wiper grabs a towel. 33 User is drying the While the user props Shower wiper is operating fully back region. herself/himself on the armrests, automatically. the shower wiper performs the drying process of the back automatically. 34 User is finishing the After drying the back region the Shower wiper is grabbing the drying process. user wants place the towel on a towel and moves it to the storage place. storage to get it for the next time.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 158 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
The back region program includes the back from the neck to the tailbone. The user can´t wash the back by herself/himself. The I-Support bath robot system may have to operate fully automatically. The user might not be able to control the motions of the soft arms with the remote control. Old and frail people might grasping the armrests for safety reasons.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 159 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-6. Core process: Posterior region shower process No. Use cases Description/Background User requirements / Technical implementation 35 User is starting the The posterior region program Motorized chair is turning backside posterior region includes the buttocks and the to the shower system. program. backside of the thighs. 36 User is getting up from The user props herself/himself on Motorized chair is supporting sit-to- the chair. the armrests and gets up from the stand transfer. chair. 37 User is initiating the While the user props herself/himself Shower hose is performing without shower hose. on the armrests, the shower hose user´s actions and gestures. performs the rinsing process of the posterior region automatically. 38 User is stopping the After rinsing, the user wants to Shower hose is moving back to the rinsing process. scrub the posterior region. starting position. Shower wiper grabs a cloth or sponge. 39 User is scrubbing the While the user props herself/himself Shower hose is performing without bottom region. on the armrests, the shower wiper user´s gestures. The shower-hose performs the scrubbing process of is in stand-by mode. the posterior region automatically. 40 User is stopping the After scrubbing, the user wants to Shower wiper is moving back to the scrubbing process. rinse the back region. starting position. Shower hose is in stand-by. 41 User is initiating the While the user props herself/himself Shower hose is performing the shower hose. on the armrests, the shower hose rinsing process without user´s performs the rinsing process of the gestures. posterior region automatically. 42 User is stopping the After rinsing the posterior region, Shower hose is moving back to the rinsing process. she/he wants to dry it. starting position. Shower wiper grabs a towel. 43 User is drying the back While the user props herself/himself Shower wiper is operating fully region. on the armrests, the shower wiper automatically. performs the drying process of the bottom automatically. 44 User is finishing the After drying the posterior region, the Shower wiper is grabbing the towel drying process. user wants to place the towel on a and moves it to the storage to get it storage place. for the next time. 45 User is sitting down on The user sits down again; maybe Motorized chair is supporting sit-to- the chair. she/he needs a short rest, because stand transfer. of the exertion. System in stand-by mode. 46 User is drying wet body The user wants to dry some body Shower wiper is grabbing once parts. parts, which may still be wet. again a towel and dries wet body parts, stimulated by the movements of the user.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 160 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
The posterior region program includes the buttocks and the backside of the thighs. The user can´t wash this body part comprehensively in a sitting position. This I-Support bath robot system may have to provide functionalities for sit-to-stand/stand-to-sit transfer and postural control during stand. The I-Support soft arms may have to operate fully automatically.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 161 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-7. Core process: Transition inside-outside and sit-to-stand transfer No. Use cases Description/Background User requirements / Technical implementation 47 User is starting the The transition program provides transition program. the transfer from inside the shower cabin outside and the sit-to-stand transfer. 48 User is confirming the When the user feels Motorized chair is moving end of the shower comfortable, she/he is outside the shower and is process. confirming the system, that adjusting the initial position. she/he has finished the shower process. 49 User is moving his The user wants to get up. The footrest is moving to the feet from the footrest stand-by position. to the floor. 50 User is standing up The user is standing up slowly Motorized chair is performing slowly. while propping on the arm rests. the sit-to-stand transfer. 51 User is going away The user is walking away Motorized chair and shower from the motorized independently or using a robot system go back in the chair. walking frame. initial position. 52 User is starting Detection of the user´s dressing movement herself/himself. 53 User is leaving the Detection of the user´s bathroom. movement
The transition and transfer program provides the transfer from inside the shower cabin outside and the sit-to- stand transfer. The I-Support bath robot system may provide a functionality for the detection of the user until she/he is leaving the bathing room.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 162 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-8. Support process: Operation, control and modification of system functionalities No. Use cases Description/Background User requirements / Technical implementation 54 The user is testing all The user is guided through the Guided demonstration of all support modes of the different modes of the device capabilities of the device. device. and is instructed of the usage of it. 55 The user wants to The modification mode is Safety, guided adjustment. change the base important to adapt system settings of the system functionalities to the current (water temperature, well-being of the user. pressure of the water jet, sequence of the shower process). 56 The user wants to This mode is important in cases Safety, guided adjustment. finish the shower of emergencies. process directly.
Table 4-9. Support process: Emergency procedures No. Use cases Description/Background User requirements / Technical implementation 57 The user is falling Despite all safety precautions Fall detection and emergency down. the I-Support bath robot system scenario. may have to provide a functionality for fall detection.
Table 4-10. Support process: System operation with visual and hearing impairments No. Use cases Description/Background User requirements / Technical implementation 58 The user might have Visual impairment/not wearing Remote and voice control of the problems to see the eye glasses within the shower system. functions of the process is a frequent health different buttons of problem in late life. the remote control. 59 The user might have Hearing impairment/not wearing Safety, guided adjustment problems to hear the hearing aids within the shower instructions. process is a common health problem in late life.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 163 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
The use cases of the support processes comprise system functionalities for the overall operation, control and modification of the I-Support bath robot system with respect merely to cognitive and sensorial impairments. As mentioned above, they still need to be specified by technical partners.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 164 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-11. Optional process: Skin care and skin inspection No. Use cases Description/Background User requirements / Technical implementation 60 User is starting the The skin care program is an The shower wiper is grabbing a skin care program. additional program for the use cloth or blanket from the. case scenarios of the shower process, when the drying process of the selected body part has finished. 61 User is initiating the The user wants to cream a body The soft arm is moving shower wiper. part. automatically to the front side of the user. 62 User is applying body The user decides, which body Shower hose is performing lotion onto the towel. lotion she/he wants to take and automatically. how much. 63 User is piloting the The user decides, which parts Shower hose is performing on soft arms. of the region should be mainly advice. creamed. 64 User is stopping the After creaming the selected Shower wiper is dropping down creaming process. body part, she/he wants to the cloth or blanket and is continue. moving back to the starting position.
65 User is starting the The skin inspection program is In the soft arm (shower wiper) of skin inspection an optional use case scenario the I-Support bath robot system program. within the shower process. is integrated a digital camera. 66 User is initiating the The user wants to inspect a Shower hose is performing shower wiper. body part. automatically or on advice. 67 User is stopping the After inspection of the selected Shower wiper is moving back to inspection process. body part, she/he wants to the starting position. The digital continue. camera is switched-off. Relatives or caregivers will check it within their next visit or send it to the doctor.
Skin care and skin inspection represent two valuable system functionalities, which could be implemented in a future step with two additional end effectors, a lotion cloth and a digital camera.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 165 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
4.3 Final use cases and technical implementation (Omega, ICCS, SSSA) This section focuses only on those use cases that analyse the I-SUPPORT operations that will be executed during the pilot studies, hence the name “final use cases”. Their description is represented at a lower level of abstraction and unrolls the flow of events for each use case. Each event is mapped onto a set of functionalities and technical requirements and this way we articulate the "what the system should do" (described by the use cases) with the "how the system does it" (functional and technical requirements). This information will form the basis for designing the I- SUPPORT system architecture in deliverable D2.1, where the set of technical requirements will elicit the subsystems and components that have to be developed and put together to form the final system. 4.3.1 Methodology (Omega) We have adopted a standard use case template for describing the use cases in a systematic way. The input fields of the template are briefly explained next. The use case ID is a unique identifier, where UC stands for Use Cases, the letters following UC are initials referring to the related use case scenario, and the number following the initials refers to the sequence of the use case within the scenario; for example UC.fd.2 is the second use case in the scenario of fall detection. The Description field briefly describes the use case. Sub process relates the use case with the sub processes number (No) in Table 4-2 – Table 4-11. Input field Conditions list the system state/conditions, which must be true before this use case can be executed. Primary actor is the one, who’s goal is being satisfied by this use case and has the primary interest in the outcome. Secondary actors are those, who have a supporting role in helping the primary actor to achieve his/her goal. Trigger is the event that initiates this use case. Main event flow narrates through a sequence of events the interaction between actors and the system. Alternative flows are branches from the main flow to handle different conditions or different ways of interaction. The flow of events in each use case is translated into functionalities and technical requirements. This linking is depicted in the diagrams that follow each use case table, where each event is resolved into associated functionalities and technical requirements described in the text right below the elliptical pattern representing the event. The arrows in the diagram indicate the order of execution of the event. The functionalities have been categorised into 11 groups and each of these groups contain a number of technical requirements. The technical requirements are designated as x.y where x is the number of the functionality group and y is the number of the technical requirement within the group, for example functionality No 1 is “To perceive the user” and comprises technical requirement No 1.1 “To localize the user wrt to the robot and the environment”, No 1.2 “To track the articulated human body”, etc. The categories of functionalities and the sets of technical requirements are all depicted in the tree diagram in Figure 4-9. At this stage of the project (M1 – M6) the functionalities listed in the use cases describe a controlled operation of the robot that is either autonomous operation or tele-manipulation. Shared control strategies have not been analysed yet and are not included in the following use cases. Their formulation requires a better understanding of the users limitations and behaviour in the shower environment and therefore is left for a later stage of the project.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 166 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
4.3.2 Use cases, associated functionalities and technical requirements (Omega, ICCS, SSSA) 4.3.2.1 Use cases scenario - stand-to-sit, transition and sit-to-stand transfer (Omega) Table 4-12. Use case: Stand-to-sit transfer and transition outside-inside Version Date Name 0.2 20/10/2015 Panagiotis Vartholomeos ID UC.ss_t.1 Title Stand-to-sit and transfer Goal/Purpose The motorized chair facilitates the stand to sit procedure by adjusting the height of the chair. The motorized chair assists the user transferring in the interior of the shower cabin Sub-processes 1 - 6 Primary actor User Secondary actors I-SUPPORT system Conditions The system has been activated by the user or by a carer. The system is aware of the user ID and hence of his/her significant characteristics: height, weight, gender, etc. Trigger --
Flow of events 1. The user makes the gesture or utters verbal control command: “I-SUPPORT enter”. 2. The chair adjusts its height in order to assists the user stand-to- sit and translates to the specified entrance position of shower cabin. 3. The independent user approaches the chair, turns the back-side to the chair, grips the armrests and sits down and places the foot on the footrest. User confirms successful stand-to-sit with the gesture or the verbal command “I-Support OK”. 4. The chair smoothly transfers the user to the starting position in the shower cabin. Alternative flow 3b. The user is impaired 1. The user approaches the motorized chair using a walking frame. 2. User fixes the walking frame and then grips the armrest of the motorized chair and hand after the other, turns backside and sits down.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 167 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 4-2. Diagram depicting the flow of events and the associated functional and technical requirements of stand-to-sit transfer and transition outside-inside use case .
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 168 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-13. Use case: Transition inside-outside and sit-to-stand transfer Version Date Name 0.2 20/10/2015 Panagiotis Vartholomeos ID UC. t_ss.2 Title Transfer and sit-to-stand Goal/Purpose The transition program provides the transfer from inside the shower cabin outside and the sit-to-stand transfer. Subprocesses 47 – 53 Primary actor User Secondary actors I-SUPPORT system Conditions The shower tasks have been completed Trigger --
Flow of events 1. The user utters verbal control command or makes the gesture: “I-SUPPORT exit”. The system informs the user through the loudspeakers that transferring is about to start. 2. The user confirms verbally or with a corresponding gesture that transfer is OK with the command “I-Support OK”. 3. The chair transfers the user slowly to the exterior of the shower cabin. 4. The user stands up either on his/her own or using a walking frame. Alternative flow 3. none
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 169 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 4-3. Diagram depicting the flow of events and the associated functional and technical requirements of transition inside-outside outside and sit-to-stand use case
4.3.2.2 Use case scenario – back region program (Omega) Table 4-14. Use case: Rinsing the back Version Date Name 0.2 20/10/2015 Panagiotis Vartholomeos ID UC.br.1 Title Rinsing the Back Goal/Purpose While the user props herself/himself on the armrests, the shower hose performs the rinsing process of the back autonomously. The user can adjust the motion of the shower robot using remote control commands.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 170 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Subprocesses 26 - 34 Primary actor User Secondary actors I-SUPPORT system Conditions The user is safely seated and is positioned according to the back- wash predefined configuration. Trigger The user made the gesture or uttered: “I-SUPPORT wash back”.
Flow of events 1. The user has uttered verbal control command or made the gesture: “I-SUPPORT wash back” and receives confirmative feedback from I-Support system. 2. User presses the start button of the tele-controller. The robot arm responds by assuming starting position above the back and waits for trigger command. 3. User presses the start button (trigger) of the tele-controller. The robot arm responds by starting pouring water and follows a pre-programmed path for rinsing the back. Instead of pressing the trigger the user can make gesture or utter verbal command. 4. The robot arm terminates the pouring water task and returns to the docking station. Alternative flow 3.b Alternatively, the user instead of pressing the button can either make a gesture or utter the verbal command “I-SUPPORT rinse”. During the process of rinsing the user can make a gesture or utter a verbal command such as: “I-SUPPORT stop” (in case of e.g., emergency), or “I-SUPPORT reset” in order to start the procedure from the beginning, “I-SUPPORT repeat” to repeat the procedure from the beginning or “I-SUPPORT ok” in any cognitive assistance. (Additional/optional triggers. Optionally, the user has the possibility to control the water with the gestures/verbal commands “I-SUPPORT water on/off”, “I-SUPPORT temperature up/down”, or “I-SUPPORT water flow up/down”). 3.b Adjust the path of the shower hose 1. The user moves the remote controller to adjust the path of the shower hose. 2. The shower hose deviates slightly from the prescribed path as long as the user moves the tele-control.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 171 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 4-4. Diagram depicting the flow of events and the associated functional and technical requirements of rinsing the back use case
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 172 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-15. Use case: Scrubbing the back Version Date Name 0.2 20/10/2015 Panagiotis Vartholomeos ID UC.br.2 Title Scrubbing the Back Goal/Purpose While the user props herself/himself on the armrests, the shower wiper performs the scrubbing process of the back automatically. The user might intervene to adjust the force profile or the path of the shower hose. Subprocesses 26 - 34 Primary actor User Secondary actors I-SUPPORT system Conditions Rinsing the back has been already performed Trigger User makes the gesture or utters verbal control command: “I- SUPPORT scrub” Flow of events 1. User makes the gesture or utters verbal control command: “I- SUPPORT scrub”. The I-SUPPORT system confirms readiness. 2. The user presses the start button of the tele-controller. The sponge is connected to the end-effector autonomously (manual mode will also be available) and the robot assumes starting position above the user’s back. The robot provides confirmative feedback. 3. User presses the start button (trigger) of the tele-controller. The robot arm starts scrubbing and follows a preprogrammed path. During the process of scrubbing the user can make a gesture or utter a verbal command such as: “I-SUPPORT stop” (in case of e.g., emergency), or “I- SUPPORT reset” in order to start the procedure from the beginning, “I-SUPPORT repeat” to repeat the procedure from the beginning or “I-SUPPORT ok” in any cognitive assistance. 4. The robot arm terminates the scrubbing task and returns to the docking station. Robot provides confirmative feedback. Alternative flow 3.b The user adjusts (slightly) the path of the sponge and the force profile of the sponge. 1. The user moves the tele-control and tele-manipulates the robotic arm end-effector. 2. The shower hose adapts the prescribed path and adjusts the force imparted on the surface of the back of the user.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 173 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 4-5. Diagram depicting the flow of events and the associated functional and technical requirements of the scrubbing the back use case
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 174 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-16. Use case: Drying the back Version Date Name 0.1 02/10/2015 Panagiotis Vartholomeos ID UC.br.3 Title Drying the Back Goal/Purpose To be done Subprocesses 26 - 34 Primary actor User Secondary actors I-SUPPORT system Conditions Trigger Flow of events 1. To be done Alternative flow none
4.3.2.3 Use case scenario – distal region program (Omega) Table 4-17. Use case: Rinsing the distal region Version Date Name 0.2 20/10/2015 Panagiotis Vartholomeos ID UC.dr.1 Title Rinsing the distal region (legs) Goal/Purpose The distal region program includes the parts of the lower leg incl. feet, the user can´t reach in a comfortable way (without moving forward, risk of falling). Subprocesses 17 - 25 Primary actor User Secondary actors I-SUPPORT system Conditions User has made a gesture or uttered verbal control command: “I- SUPPORT wash legs” Motorized chair has adjusted its position so that the user faces the I- Support robot
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 175 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Trigger User makes gesture or utters verbal control command: “I-SUPPORT rinse” then presses the start button of the tele-controller.
Flow of events 1. User presses the start button of the tele-controller. 2. The robot arm base lowers to the height of the user’s legs The robot arm end-effector assumes starting position above the left knee. 3. User presses the start button (trigger) of the tele-controller. The robot arm starts pouring water and follows a preprogrammed path for rinsing the lower leg. 4. The robot arm terminates the pouring water task of the left leg. The robot arm repeats the procedure for the right leg. Alternative flow 3.b The user instead of pressing the button can either make a gesture or utter the verbal command “I-SUPPORT rinse”. During the process of rinsing, the user can make a gesture or utter a verbal command such as: “I-SUPPORT stop” (in case of e.g., emergency), or “I-SUPPORT reset” in order to start the procedure from the beginning, “I-SUPPORT repeat” to repeat the procedure from the beginning or “I-SUPPORT ok” in any cognitive assistance. 3.c The user adjusts the path of the shower hose using remote controller 1. The user moves the tele-controller to adjust the path 2. The robot arm deviates from prescribed path according to tele-manipulation commands 3.d The user adjusts the path of the shower hose manually. 1. The user grasps the robot arm and moves it according to his/her will. 2. The robot arm controller renders the arm transparent to the user and assists the physical human/robot interaction
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 176 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 4-6. Diagram depicting the flow of events and the associated functional and technical requirements of the rinsing the distal region use case .
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 177 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-18. Use case: Scrubbing the distal region Version Date Name
0.2 20/10/2015 Panagiotis Vartholomeos
ID UC.dr.2
Title Scrubbing the distal region (lower legs)
Goal/Purpose While the user props herself/himself on the armrests, the shower wiper/sponge scrubs the lower legs. The user might intervene to adjust the force profile or the path of the sponge.
Subprocesses 17 - 25
Primary actor User
Secondary actors I-SUPPORT system
Conditions Rinsing the legs has been already performed
Trigger User makes the gesture or utters the verbal control command: “I- SUPPORT scrub” then presses the start button of the tele-controller
Flow of events 1. User makes the gesture or utters verbal control command: “I- SUPPORT scrub”, the system confirms readiness and when user is ready presses the start button of the tele-controller. 2. The user presses the start button of the tele-controller. The sponge is connected to the end-effector autonomously (a manual mode is also available) and the robot arm assumes position above the user’s knee, provides confirmative feedback and waits for trigger command. 3. User presses the start button (trigger) of the tele-controller. The robot arm starts scrubbing and follows a preprogrammed path for scrubbing the lower leg (shin, calf, foot, etc.). During the process of scrubbing the user can make a gesture or utter a verbal command such as: “I-SUPPORT stop” (in case of e.g., emergency), or “I-SUPPORT reset” in order to start the procedure from the beginning, “I-SUPPORT repeat” to repeat the procedure from the beginning or “I-SUPPORT ok” in any cognitive assistance. 4. The robot arm terminates the scrubbing task and returns to the docking station.
Alternative flow 3.b The user adjusts (slightly) the path of the sponge and the force profile of the sponge using the tele-controller.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 178 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
1. The user moves the tele-control and tele-manipulates the robotic arm end-effector 2. The soft-robot end-effector adapts the prescribed path and adjusts the force imparted on the surface of the back of the user. 3.c The user adjusts the path of the shower hose manually 1. The user grasps the robot arm and moves it according to his/her will. 2. The robot arm controller renders the arm transparent to the user and assists the physical human/robot interaction
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 179 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 4-7. Diagram depicting the flow of events and the associated functional and technical requirements of scrubbing the distal region use case
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 180 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-19. Use case: Drying the distal region Version Date Name 0.1 02/10/2015 Panagiotis Vartholomeos ID UC.dr.3 Title Drying the distal regions (legs) Goal/Purpose To be done Subprocesses 17 - 25 Primary actor User Secondary actors I-SUPPORT system Conditions Trigger
Flow of events 1. To be done
Alternative flow none
4.3.2.4 Use case scenario – Posterior Region program (Omega) Table 4-20. Use case: Washing the posterior region Version Date Name
0.1 20/10/2015 Panagiotis Vartholomeos
ID UC.bot_r.1
Title Rinsing the posterior (bottom) region
Goal/Purpose The bottom region program includes the buttocks and the backside of the thighs that the user can´t wash in a sitting position.
Subprocesses 35 - 46 Primary actor User Secondary actors I-SUPPORT system
Conditions Motorized chair is turning backside to the shower system. The chair seat has aperture for facilitating washing the bottom.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 181 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Trigger -
Flow of events 1. The user makes the gesture or utters verbal control command: “I-SUPPORT wash bottom”. User presses the start button of the tele-controller. 2. The robot arm assumes starting position beneath the seat aperture. 3. User presses the start button (trigger) of the tele-controller. 4. The robot arm starts pouring water and follows a preprogrammed path for rinsing the bottom. 5. The robot arm terminates the rinsing task and returns to the docking station.
Alternative flow 3.b Adjust the path of the shower hose 1. The user moves the remote controller to adjust the path of the shower hose. 2. The shower hose changes the prescribed path according to the tele-control commands. 3.c Adjust the intensity of the water flow 1. The user moves the remote controller to adjust the water jet intensity. 3.d Alternatively, the user instead of pressing the button can either make a gesture or utter the verbal command “I-SUPPORT rinse”. During the process of rinsing the user can make a gesture or utter a verbal command such as: “I-SUPPORT stop” (in case of e.g., emergency), “I-SUPPORT reset” in order to start the procedure from the beginning, “I-SUPPORT repeat” to repeat the procedure from the beginning or “I-SUPPORT ok” in any cognitive assistance. (Additional/optional triggers. Optionally, the user has the possibility to control the water with the gestures/verbal commands “I-SUPPORT water on/off”, “I-SUPPORT temperature up/down”, or “I-SUPPORT water flow up/down”).
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 182 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Figure 4-8. Diagram depicting the flow of events and the associated functional and technical requirements of rinsing the posterior region use case
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 183 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-21. Use case: Drying the posterior region Version Date Name
0.1 02/10/2015 Panagiotis Vartholomeos
ID UC.bot_r.3
Title Drying the bottom regions (legs)
Goal/Purpose To be done
Subprocesses 35 - 46
Primary actor User
Secondary actors I-SUPPORT system
Conditions
Trigger To be done
Flow of events 1. To be done
Alternative flow none
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 184 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
4.3.2.5 Use case scenarios – Operation, control and modification of system functionalities (ICCS, SSSA) Table 4-22. Use case: Interface commands Version Date Name 0.1 20/10/2015 Panagiotis Vartholomeos ID UC.int_r.1 Title Interface commands Goal/Purpose Include system interface commands regarding comfort and usage settings not tied to specific washing actions Subprocesses 54 - 59 Primary actor User Secondary actors I-SUPPORT system Conditions During system usage in all scenarios. Trigger User makes gesture or utters the command: “I-SUPPORT OK” “I-SUPPORT Scrub” “I-SUPPORT Rinse” “I-SUPPORT Repeat” “I-SUPPORT Stop” “I-SUPPORT Dry” “I-SUPPORT Wipe” “I-SUPPORT Cream” “I-SUPPORT Temperature Up” “I-SUPPORT Temperature Down” “I-SUPPORT Water On” “I-SUPPORT Water Off” “I-SUPPORT Increase flow” “I-SUPPORT Decrease flow” Flow of events The system applies the command. This should be relevant to its current state since these commands are state change requests.
Alternative flow none
Notes These commands are subject to adaptation to the final system, patient and experiment capabilities.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 185 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-23. Use case: User identification Version Date Name
0.1 12/10/2015 Vincenzo Genovese Angelo Sabatini
ID UC.ui.1
Title User identification
Goal/Purpose The main purpose of the user identification is that to establish if the user is authorized or not to interact with the I-SUPPORT system. User identification represents the necessary preliminary interaction between the user and the I-SUPPORT system. The procedure includes the possibility of ending with the automatic transfer of a user record from the wearable device (the smartwatch) to the I-SUPPORT controller .
Subprocesses 54 – 59
Primary actor The user.
Secondary actors None.
Conditions The user wears the smartwatch. The smartwatch must be connected via Bluetooth to an Android platform located in the workspace and operational on the WLAN.
Trigger The user presses twice the home button on the smartwatch.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 186 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Flow of events 1. The smartwatch screen shows a simplified keyboard (cell phone style); 2. the user types his personal code and press the OK button; 3. if the user is not recognized a wrong code message is visualized and he can restart to edit his personal code (point 2); 4. if the user is recognized then a message box is visualized. In the message box is reported the real name of the user and the OK button to be pressed in order to end the whole procedure; 5. the user record is automatically transferred from the wearable device to the I-SUPPORT system.
The flow of events for the user identification is related to the functionality 1.11 reported in the functional tree.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 187 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-24. Use case: Environmental monitoring
Version Date Name 0.1 12/10/2015 Vincenzo Genovese Angelo Sabatini ID UC.em.1 Title Environmental monitoring Goal/Purpose Improve the user comfort and safety during his time in the bathroom. Subprocesses 54 – 59 Primary actor The user. Secondary actors The staff, friends and next of kin. Conditions The air monitoring system and the water monitoring system are operational and connected over the WLAN.
Trigger 1. The air quality is poor; 2. the water flow is not comfortable; 3. the water temperature is not comfortable 4. the air quality and/or the water status can cause safety issues.
Flow of events 6. In the case of safety issues the a message is sent to the I- SUPPORT controller; 7. a request for assistance is submitted an acoustic alarm is activated by the smartwatch; 8. when the request for assistance is detected by the staff the acoustic alarm is stopped.
The flow of events for the environmental control is related to the functionality 2.2 reported in the functional tree.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 188 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-25. Use case: Assistance request Version Date Name 0.1 12/10/2015 Vincenzo Genovese Angelo Sabatini ID UC.ar.1 Title Assistance request Goal/Purpose Provide assistance to the user in case of need. The request of assistance is based on the interaction between the smartwatch and the Android platform (located in the workspace) acting as range extender. Subprocesses 54 – 59 Primary actor The user. Secondary actors The staff, emergency personnel, call center, friends and next of kin. Conditions The user wears the smartwatch. The smartwatch must be connected via Bluetooth to an Android platform located in the workspace and operational on the internet and/or phone line. Trigger The user presses a button on the smartwatch screen to send a request for assistance. Flow of events 1. After the request for assistance was submitted an acoustic alarm is activated by the smartwatch; 2. when the request for assistance is detected by the remote personnel assigned to the rescue then the acoustic alarm is stopped and a message box of confirmation of the started rescue is showed on the screen. The flow of events for the assistance request is related to the functionality 1.12 reported in the functional tree.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 189 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-26. Use case: Fall detection
Version Date Name 0.1 12/10/2015 Vincenzo Genovese Angelo Sabatini ID UC.fd.1 Title Fall detection Goal/Purpose The purpose of fall detection is that to provide assistance to the user in case of fall. The request of assistance is based on the interaction between the smartwatch and the Android platform (located in the workspace) acting as range extender. Subprocesses 54 – 59 Primary actor The user. Secondary actors The staff, emergency personnel, call center, friends and next of kin. Conditions The user wears the smartwatch. The smartwatch must be connected via Bluetooth to an Android platform located in the workspace and operational on the internet and/or phone line. Trigger A fall of the user was detected.
Flow of events 1. An acoustical alarm is activated by the smartwatch and a message box asking for fall confirmation is showed on the screen; 2. if the user doesn't confirm the fall then the acoustic alarm is stopped and the fall detection is restarted; 3. if the user confirms the fall or if a predetermined period of time is expired without confirmation a request for assistance is submitted; 4. when the request for assistance is accepted by the remote personnel assigned to the rescue then the acoustic alarm is stopped and a message box of confirmation of the rescue is showed on the screen.
The flow of events for the fall detection is related to the functionality 1.5 reported in the functional tree.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 190 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
Table 4-27. Use case: Dead man detection Version Date Name 0.1 12/10/2015 Vincenzo Genovese Angelo Sabatini ID UC.dmd.1 Title Dead man detection Goal/Purpose The purpose of dead man detection is that to provide assistance to the user in case of loss of consciousness. The request of assistance is based on the interaction between the smartwatch and the Android platform (located in the workspace) acting as range extender.
Primary actor The user. Secondary actors The staff, emergency personnel, call center, friends and next of kin. Conditions The user wears the smartwatch. The smartwatch must be connected via Bluetooth to an Android platform located in the workspace and operational on the internet and/or phone line. Trigger No physical activity has been detected in a predetermined period of time. Flow of events 1. an acoustic alarm is activated and a message box asks to not confirm the detection; 2. if the user doesn't respond after a second predetermined period of time is expired the request for assistance is submitted; 3. when the request for assistance is detected by the remote personnel assigned to the rescue then the acoustic alarm is stopped and a message box of confirmation of the rescue is showed on the screen. The flow of events for the dead man detection is related to the functionality 1.6 reported in the functional tree.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 191 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
4.3.3 Tree diagram of functionalities and technical requirements (Omega)
Figure 4-9. Tree diagram of I-SUPPORT functionalities and technical requirements
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 192 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
4.4 Summary (Bethanien) Based on comprehensive model of impairments, limitations and user requirements, we described initial use case scenarios from a clinical perspective (section 4.2). They were presented and discussed at a project meeting in Athens (September 17-18). From the core process the back and distal region use case scenarios have been included for future validation studies. The core region use case scenario has been excluded as well as the optional use case scenarios for skin care and skin inspection. The specification of the transfer/transition and posterior region use case scenarios depends on the functionalities of the motorized chair, has to be further specified within the course of the project. In addition, the use case scenarios of the support processes will need specification from technical partners. In section 4.3 we presented the final use cases, which have been amended in cooperation with technical partners including their technical perspective and identification of functionalities. At the present time, is not yet clear, whether these use cases will be amended by results of the qualitative survey of bathing attitudes and behaviors of users and carers. The final use cases will be completed in the course of project development and described in a later report.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 193 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.
Horizon 2020 ICT-Supported Bath Robots
5 Summary of report Authors: Prof. Dr. Barbara Klein, Sarah-Sabrina Kortekamp, Holger Roßberg (FRA-UAS)
Chapter 1 depicts a short user definition for the I-SUPPORT robot system. This definition also entails inclusion criteria for the acquisition of participants within the scope of the I-SUPPORT project. Two inclusion criteria are named: The first is a dependency of the possible user regarding bathing tasks. This can be accessed via the ADL item bathing. Second, it was suggested to exclude people with severe cognitive impairments (MMSE scores < 18), but to include persons with moderate cognitive impairment (MMSE scores 18-24) and persons with no cognitive impairment (MMSE scores > 24). In chapter 2, user requirements are developed from a clinical perspective based on the International Classification of Functioning, Disability and Health (ICF). Functional status and impairments were classified in six categories. At the end of each section the consequences for the bathing/showering activities are derived. These findings are then transitioned to potential use cases and further implemented in chapter 4 “Use cases and system functionalities”. Findings in chapter 3 are based on interviews with primary users (frail, elderly) and secondary users (formal and informal carers; healthcare professionals). Results relate to findings of chapter 2, e.g. especially secondary users stated that the skin might be very sensitive, emphasized the importance of communication between the system as well as the necessity of cleaning skin folds and genitals/buttock. But also security aspects were mentioned like a stand-to-sit/sit-to-stand transfer or a protection against scalding. Additionally, primary users expect some wellness functionalities, like a massaging jet in order to relieve back pain. A point not considered so far is the cleaning and maintenance of the I-SUPPORT system. Primary as well as secondary users stressed the importance that the system is easy and with very few efforts to clean and maintain. In chapter 4 the final use cases are presented. Use cases analysing the I-SUPPORT operations will be implemented in the study design of the upcoming validation studies. From the user requirements and the technical requirements use cases of the I-SUPPORT system are derived.
This project has received funding from the European Union‘s Horizon 2020 Research and Innovation Framework 194 Programme, Societal Challenge 1 (DG CONNECT/H) under grant agreement No 643666, Activity PHC-19-2014, ICT- Supported Bath Robots. www.i-support-project.eu.