1 Introduction
Upon completing an inpatient rehabilitation course, most patients discharged from the hospital face medical complications, which places them at high risk for readmission [1, 2]. Without proper exercise programs, equipment, and guidance by trained exercise professionals, to promote their medically proven health care, they are falling into the abyssal valley of death between hospital care and community sports. This is especially true for individuals with a spinal cord injury or stroke, whereby the rendered paralysis usually results in varying degrees of impaired mobility [3, 4].
In the absence of an appropriately equipped environment conducive to promoting self-directed care in health and medical management, individuals with disabilities are denied equitable participation in many aspects of community life. And thus, after receiving rehabilitation treatment from an inpatient hospital setting due to an illness or accident that results in disabling conditions, patients require a systematic medical-based and rehab-focused sports and exercise program within their dwelling communities.
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These programs should be comparable to or mimic the services rendered from the perspective of an institutional setting. It should also serve as a vital component in the overall health management and continuity of care within a community environment. However, local communities lack the necessary infrastructure—workforce, space, equipment, and devices— encompassing a program of services that focuses explicitly on smart medical-based and rehab-focused exercise and sports activities catered to these individuals [5].
Furthermore, from an economic perspective, studies have substantiated cost-benefit aspects based on total annual medical and healthcare expenses for individuals with disabilities by comparative studies analyzing expenditure outcomes between individuals with disabilities who engage in some form of regular exercise activity as opposed to those who did not regularly participate in exercise programs [6, 7].
And thus, as the marginalization of the disabled population—inequity of essential healthcare amid a public health crisis—continues to be the social norm globally [8], such a provision for this population undoubtedly yields equitable opportunity in promoting their health and well-being as that of the non-disabled members of their communities at large [4].
We intend to build a system that allows people with disabilities to continuously improve their health by alleviating modifiable factors and related challenges after being discharged from the hospital. This study aims to promote a multi-ministerial data-driven smart health system using a digital health living lab platform as a testbed program for providing lifestyle exercise and sports-related physical education for community-dwelling individuals with disabilities.
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2 Paper Preparation
The common aim was to promote the activities and exercises of people with disabilities in the community through joint efforts of multi-ministries to integrate resources and infrastructure from the medical, technological, economic, and social sectors. Through a governmental competition among 108 candidates, strategic planning with a large grant was awarded to the National Rehabilitation Center (NRC) in the Ministry of Health & Welfare by joint efforts from the three related ministries: Ministry of Culture-Sports & Tourism, Ministry of Science & Technology, Information & Communication, and Forest administration. To fulfill the tasks, appropriate requests for proposals (RFP) were designed by each ministry.
The collaboration of tasks and assignments span broadly under the tutelage of four governmental ministries: 1) the Ministry of Health and Welfare, which oversees medical exercise services and its distribution as a leading role; 2) the Ministry of Culture, Sports and Tourism, which oversees exercise programs in the community; 3) the Ministry of Science, Technology Information and Communication (ICT), which oversees exercise-related data service and information technology.
The Ministry of Health & Welfare, NRC, has announced 21 projects as a leading role. The individual projects are categorized into four disciplines: 1) “Partnership and Collaboration,” 2) “Equipment and Biometric Technology,” 3) “Data Integration,” and 4) “Exercise Programs and Services.” The assigned projects by recipients of various academic institutions and business corporations are summarized as a figure which is not included herein but is available as a supplement. Each task consists of a consortium of universities and business corporations collaborating on delegated sub-tasks, ultimately establishing the NRC ‘Smart Rehabilitation Exercise Living Lab Center'.
2.1 Roadmap and Plan of Action
The defined roadmap for this multi-faceted endeavor of building the smart rehabilitation exercise living lab center requires integration with collaborative efforts from multi-ministerial forces. The collaborating entities will work toward data acquisition and service connection using input from the public and private organizational resources. Field application within the designed living lab center will also require expert guidance from clinicians, therapists, and allied health professionals from disability sports and physical education arenas. The action plan spans a three-year timeline focused on accomplishing three broad aspects.
The first year (2021) was dedicated to the detailed design of the smart medical living lab platform. This was achieved by collecting opinions from the multi-ministerial council and advice from expert advisory groups. Participating entities successfully received institutional review board approval for clinical trials involving human participants. Platform integration was also accomplished by connecting with the Ministry of Health and Welfare representatives to oversee medical services distribution, the Ministry of Culture, Sports and Tourism to supervise the exercise and sports activities, and the Korea Forest Service.
In 2022, Year 2, the focus was to set up and execute operation plans for the smart medical living lab. The center will be set up and housed at Korea National Rehabilitation Center. The prototype module development and integration of various established platforms will be connected under the multi-ministerial linkage efforts. The recruitment efforts and enrollment of study participants for the preclinical trials with testbed services of the program activities will get underway.
The focus in the final period, Year 3, is to verify and stabilize operations efforts of the disability exercise center via expansion establishment of the model nationwide. The final evaluation and assessment will be performed along with data linkage with the multi-ministerial entities.
The described pilot services in physical education and program of activities will be rendered at the living lab center of KNRC. The center will be equipped with data servers to store continuously acquired data and accumulate pertinent information. We envision an encrypted data collection and acquisition system, whereby newly acquired data will be merged with data information from original records of individuals generated during the inpatient hospital course.
Twenty-one tasks have been delegated across various institutions and corporations. These include four assignments for systems, seven for equipment and device development projects, five studies in physical education and exercise programs, and five assignments in data linkage.
2.2 Pilot Test Run
We acquired preliminary data using the above data set and conducted a testbed run. The study sample (n = 7) comprised five athletes and two coaching staff from the Korea Wheelchair Rugby Association. All participants were of male gender and had a varying cervical level of neurological injury (C5-C6-C7); one with thoracic level injury (T3). The para-athletes were initially examined by a staff physiatrist trained in spinal cord injury medicine. The basic clinical characteristics of the participants were collected followed by an assessment of ‘functioning status’ using the 6-min Walk Test (6-MWT) via wheelchair propulsion.
3 Results
The dataset we envision collecting via purchased equipment, manufactured devices, apparatus, and survey questionnaires from personal interviews comprises 208 pieces of information. This dataset is broadly categorized into three sub-datasets: 1) Personal information (PI), 2) Evaluation Data, and 3) Exercise Data. In the Evaluation Data category, it consists of four sub-categories. These include medical and community records about general health conditions, which were evaluated, 1) during hospitalization (dH), 2) in clinics after hospitalization (iC), 3) from a personal trainer (PT), and 4) National Insurance in South Korea (NI). These periodical evaluations are able to determine each individual's health condition at the time of clinical evaluations, which would be compared to community exercise intervention programs. The Exercise Data category consists of two sub-categories. These include 1) the biometrics of exercise (BE) using physiological sensors, e.g., heart rate, oxygen saturation during the exercise, and 2) the amounts of exercise (AE), frequently described by parameters of Frequency (# per a week), Intensity (Exertion and speed), Time (mins per one time), Type (Aerobic/Anaerobic, Cardiac, Strengthening, Resistance, etc.). If there exist intersection parameters in evaluation/exercise sub-categories, each recorded time would be different to discriminate the health conditions.
These evaluation data can be further categorized into six sub-datasets in terms of data characteristics. Table 1 summarizes the demographic information (#1–10); Table 2 shows (1) Body composition (#11–30), (2) Administrative medical and health data (#31–40: medical and surgical histories; lab draws; diagnoses), (3) Functioning status (#41–90: physiology; biomechanics; body function test), (4) Quality of Life and physical assessment (#91–101: social; mental; general). Table 3 shows the exercise data (#102–130) summarizing the exercise performance in the program of activities. These data were examples of parameters collected from the manufactured devices: balance & coordination exercise; anaerobic exercise; aerobic exercise, which is generated by the exercise equipment manufactured by the participating companies in current projects.
Table 1.
Clinical characteristics (Personal Information (PI))
Code | Data | Units | Collection Method | ||
|---|---|---|---|---|---|
1 | Demographics | HD0001 | Name | Initials (KJB) | PI |
2 | HD0002 | Age | Yrs | PI, dH | |
3 | HD0003 | Sex/Gender | M = 0; F = 1 | PI, dH | |
4 | HD0004 | Date of Birth | - | PI | |
5 | HD0005 | Marital Status | N = 0; Y = 1 | PI | |
6 | HD0006 | Offspring(s) | #Count | PI | |
7 | HD0007 | Employment status | N = 0; Y = 1 | PI | |
8 | HD0008 | EtOH & Tobacco use | N = 0; Y = 1 | PI | |
9 | HD0009 | Disability Level category | - | PI, dH | |
10 | HD0010 | Social History | PI |
Table 2.
Evaluation data
Table 3.
Exercise data
102 | Data from Prototype Devices Developed | Aerobic Exercise | HR0001 | N of Performance | Number count# | AE-F |
103 | HR0003 | Force | Kg | BE | ||
104 | HR0004 | Angular Velocity of Arms | rad/s | BE | ||
105 | HR0005 | Angular Acceleration of Arms | mm/s2 | BE | ||
106 | HR0006 | Oxygen Saturation | SpO2 | BE | ||
107 | HR0007 | Heart Rate | bpm (beat per minute) | BE | ||
108 | HR0008 | Performance Time | t/m/s | AE-T | ||
109 | HR0009 | Speed/Distance (Ergonometer) | km/h | AE-I | ||
110 | HR0010 | Pedal RPM | rpm | AE-I | ||
111 | HR0011 | Calories | kcal | AE | ||
112 | HR0012 | Total Time | t/m/s | AE-T | ||
113 | Anaerobic Exercise | HR0013 | Joint Position | (x,y,z) | BE | |
114 | HR0014 | Joint Angle | ° | BE | ||
115 | HR0015 | Isometric Force | N | AE-I, BE | ||
116 | HR0016 | Isokinetic Power | W | AE-I, BE | ||
117 | HR0017 | Isotonic Power | W | AE-I, BE | ||
118 | HR0020 | Joint Angular Velocity | rad/s | AE-I, BE | ||
119 | HR0021 | Joint Angular Acceleration | mm/s2 | AE-I, BE | ||
120 | Balance & Coordination | HR0022 | Hand-eye coordination | n/m | BE | |
121 | HR0023 | Ability to move L/R | % | BE | ||
122 | HR0025 | Ability to move forward | % | BE | ||
123 | HR0026 | Stand up from sitting | % | BE | ||
124 | Walking | HR0030 | Walking | BE | ||
125 | HR0031 | Standing up | % | BE | ||
126 | HR0032 | Squat | % | BE | ||
127 | HR0033 | Walking distance | km | AE-I, BE | ||
128 | HR0034 | Walking speed | km/h | AE-I, BE | ||
129 | HR0035 | Power Assist | % | BE | ||
130 | HR0036 | N of steps | Number count# | AE-I, BE |
3.1 Results of Pilot Study
The participants were all male and had a mean age of 29.7, a range of 19 to 46, and a median age of 25. One of the participants had a thoracic level injury (T3), while the remaining six were cervical level injuries. These and other basic characteristics are summarized in Table 4. The parameters measured in the 6-MWT included heart rate (HR), rate of perceived exercise (RPE), respiratory failure (RF), metabolic equivalence in exercise test (METs), maximal oxygen consumption (VO2/kg(ml)), minute ventilation (VE), respiratory exchange ratio (RER(R)), distance propelled in meters, and reason for discontinuing when applicable. The measurement also included resting BP and HR and post-exercise BP and HR. The acquired data are reported in Table 4 (Personal Information as “Clinical Characteristics”), however Table 3A (Functioning Status as measured by the “6-MWT”) data are not reported herein but are available as a supplement.
Table 4.
Clinical characteristics
Participant | Age Years | Gender | Neurological Injury Level | Weight (kg) | BMI |
|---|---|---|---|---|---|
A | 19 | M | C6–C7 | 53 | 16.0 |
B | 24 | M | C5–C6 | 70 | 23.4 |
C | 29 | M | C7 | 83 | 25.3 |
D | 46 | M | T3 | 75 | 24.5 |
E | 25 | M | C6 | 73 | 22.5 |
F | 23 | M | C6–C7 | 56 | 17.9 |
G | 42 | M | C6–C7 | 72 | 22.0 |
4 Discussion
Upon the onset of an illness or injury requiring medical treatment, patients are usually admitted to a hospital facility to receive clinical care. Herein, patients undergo appropriate medical and or surgical treatment for their illnesses. The primary focus is strictly medical stabilization and health maintenance. During this inpatient hospital phase--toward a path of recovery--medical professionals of varying disciplines manage and provide essential care for patients, including physicians and allied health professionals.
Under appropriate settings, a medically prescribed rehabilitation course may also be indicated in many situations, especially following the onset of a disabling injury. The goal from a rehabilitation perspective is to enhance patients’ functioning ability, thereby ultimately ensuring a safe and stable transition phase in their recovery toward community re-integration. This is achieved through a prescribed rehabilitation program consisting of conventional occupational (OT) and physiotherapies (PT). Depending on the facility, this program may include a specific training period focusing on activities of daily living (ADL) within a simulated home and community environment before discharge.
This simulated home and community environment—a data-driven smart medical living lab center housed at the National Rehabilitation Center of Korea—serves as the fulcrum. The linkage of pilot services’ multi-ministerial rehabilitation program will be linked to the disabled population throughout the local communities. Immediately after discharge from the hospital, patients will transition to a “smart medical healthy” living lab environment before returning to their respective domiciles in the community. Patients will spend several days in a simulated home and community setting to undergo training in various activities of daily living. The medical-based program focuses on rehabilitation exercise and sports activities specifically designed to aid these individuals in developing a habit of management in self-directed care and health maintenance. Unlike the inpatient acute hospital course, the setting herein does not require licensed clinicians to provide these services. And thus, participating individuals will be instructed and trained by non-clinical professionals with expertise in disability sports and physical education to ultimately ensure safe functioning status toward a stable community re-integration.
4.1 Linkage of Multi-ministerial Rehabilitation Platforms
The testbed participants will be recruited from the NRC inpatient population as part of their discharge planning from acute inpatient rehabilitation and individuals with chronic disabilities from the local community. The collected hospital data will be merged with newly acquired information under the tutelage of the four governmental ministries to accumulate a data bank using the onsite server.
A living lab testbed built and operated by the NRC is currently in the development and establishment phase. It is expected to open and get underway by recruiting participants from the National Rehabilitation Center’s inpatient population and local communities. A smart health medical rehabilitation-based and data-driven living lab will render the pilot service R&D efforts designed to provide rehabilitation and physical education programs for individuals with a disability in the local community.
4.2 Effects of a Collaborative Research & Development
The overarching benefits of this integrative research and development (R&D) are multi-fold. The many advantages are realistic and expected to infiltrate many sectors of our society.
Medical benefits will improve healthcare services through an integrated rehabilitation model with increased therapeutic efficacy expected to result via the rehabilitation exercise guidelines applied to various disease models.
The benefits from a ‘technology’ perspective are also multi-fold. We expect that there will be further advanced development of technology for enhanced data acquisition that will trigger commercialization with the expansion of various contents applicable to other research and development areas.
The economy can also benefit by an overall reduction in the cost of healthcare for all ages and social classes, especially for the elderly and marginalized population. This will likely be achieved by providing welfare services for the financially destitute and socially disadvantaged. Industries can also work hand-in-hand to benefit from the expansion of the technology development into overseas markets, fueling the creation of job opportunities for the unemployed.
Social advantages include reduced healthcare costs and mortality by promoting a healthy lifestyle and self-directed care in health management. This will mainly apply to the general population as people are aging and living with more chronic disabilities. The creation of more social platforms is also foreseeable in advantageous ways yielding an artificial intelligence and smart device-driven society.
4.3 Pilot Study of Para-Athletes
Our initial testbed run yielded results comparable to output under the circumstances from individuals with functioning disabilities stemming from spinal cord injury. The acquired data were not statistically analyzed in any specific manner or for comparison purposes. The raw data are provided to convey the intent of pursuing the upcoming complete study applying “Clinical characteristics” (Personal information; Table 4) and “Functioning status” (6-MWT; Table 4A) from the proposed data set. Our goal is to substantiate the effects of the smart-medical living lab simulated herein, which will apply to and ultimately lead to a governmental establishment of these fitness program centers specifically designed for individuals living with disabilities nationwide.
5 Conclusion
Patients with disabling conditions due to an acute onset of illness or devastating injury are discharged without proper training and education for safe return to and participation in their communities. They require a systematic medical-based and rehab-focused sports and exercise program accessible within their respective communities. A smart medical rehabilitation-based and data-driven living lab center can provide the necessary platform for successful community re-integration.
Acknowledgments
We thank Dr. Junghwan Kim and Dr. Hyosun Kwon at National Rehabilitation Center for their helpful comments and great support on this project. We also extend our appreciation to Mr. Yunho Kim and the pilot test participating athletes of the Korea Wheelchair Rugby Team.
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