Problem Statement/Research Question and Background

Background: Children and adolescents with physical or developmental disabilities undergo

rehabilitative therapy to learn new motor skills, maintain existing skills and support their capacity
for self-care and independent living.1 Rehabilitation success, including preventing the
development of secondary impairments, depends on sufficient therapy practice dosage.2,3
However, therapy amount and frequency is often determined by budgetary factors instead of
children’s needs.4,5 As such, home activity programs play an essential role in increasing practice
dosage.1,4 Child and family adherence to conventional activity programs is historically poor.6 Poor
adherence has been attributed to a lack of motivating, individually customizable practice tasks.7
Problem statement: Therapists are challenged to find low-cost therapeutic activities that
elicit required movements and sustain children’s motivation to engage in repeated,
individualized practice. Technologies such as virtual reality (VR) and iPads/tablets are exciting
options that can overcome adherence issues by providing motivating, game-based movement
opportunities.8,9 However, most VR systems are costly, inaccessible, or too challenging, and tablets
have a small game play surface that can’t elicit head, trunk or full body movements. There is a
crucial need for an accessible, user-friendly tool that capitalizes on the motivational attributes of
these technologies and adjusts to meet motor and cognitive needs.
What are the needs of children with disabilities? Functional impairments in motor learning,
self-direction, and self-care abilities in children and adolescents with severe physical and/or
developmental disabilities such as cerebral palsy, traumatic brain injury, or developmental delay
necessitate long-term rehabilitation.4,10 These limitations are lifelong, require individualized
rehabilitation services, and impact capacity for independent living and quality of life.10 Motor
learning impairments necessitate abundant practice to elicit functional change and require
abundant feedback.3 Children with mobility impairments can have limited access to the
surrounding environment, reducing opportunities for play and problem-solving that supports skill
learning.1 Lower self-competence in children and adolescents with disabilities as compared to
typically developing peers limits opportunities for self-directed play.11
Lack of adherence to exercise limits the practice dosage required for function. Therapeutic
time constraints require that most activity repetitions occur outside of a therapy context, so parents
and caregivers need home-based, customizable activity options. It is challenging to develop
engaging, accessible and low-cost activities that motivate children with disabilities to increase
practice dosage.3 To learn new skills, children require abundant, progressive, and challenging
practice opportunities.2 However, evidence suggests that patients and families demonstrate limited
engagement and adherence to unsupervised home activity programs,6,7 despite the fact that
adherence and outcomes are positively correlated.6,12 Poor motivation, in addition to logistical
factors such as time and family stressors, affect adherence.6
Technology can motivate children to practice. Motivation is the psychological property that
encourages or sustains actions toward a goal.13 Motivation can mediate brain changes (i.e.
neuroplasticity) that influence motor learning.14,15 Children are more motivated by
technologically-based interventions as compared to conventional practice,16,17 and motivation is
associated with improved rehabilitation outcomes.18 Motivating technology incorporates gaming
principles of rewards, appropriate challenge, feedback, choice, interactivity, and clear goals.19
iPads and tablets are popular therapy tools used to stimulate both small movements and cognitive
processes through a huge variety of apps.9 However, these devices have a limited play space (i.e.,
movements are restricted by the size of the screen), do not encourage bimanual coordination, do
not elicit functional movement and do not incorporate grasping, object manipulation or sensory
stimulation from touching different surfaces. Virtual reality (VR) video games are also popular,
effective intervention tools to motivate children to use body movements to interact with onscreen
simulations.8,20,21 However, inexpensive, off-the-shelf VR games are too challenging for young
children, children with perceptual or cognitive challenges, or those with severe physical
impairments.22,23 Rehabilitation-specific VR systems are costly and difficult to use at home or in
multiple settings, which severely limits their relevance.
Methods/Approach/Solutions Considered
We began the process of developing a low-cost rehabilitation tool that addresses these issues, by
asking for input from therapists at Spaulding Rehabilitation Hospital and Franciscan Children’s
Hospital. Our guiding principles were cost, bridging digital and physical interactions, flexibility to
address multiple needs and cognitive abilities, game play using hand, foot or head movements,
durability to energetic physical play, and opportunities for child-led functional play. We also
wanted therapists to be able to keep track of patient progress. We assembled a team of electrical,
computer and mechanical engineering students who brainstormed through various iterations to
construct the device and create its software application.
1. Functionality iteration #1: Makey makey
We started with Makey
MakeyTM, a commercially
available product that turns
any conductive material
(play-dough, fruit, metal,
water) into a keyboard
interface. The low cost and
flexibility of this tool
appealed to us, as did the
existing open source games
using the Scratch interface
(https://scratch.mit.edu), Figure 1. First prototype using the Makey Makey and play dough.
and the possibility that game play could involve accessible materials. However, after
experimenting with how to adhere these materials to a board, realizing it was difficult to maintain
the circuit by ‘grounding’ the user, and recognizing that setting up the alligator clips was time-
consuming for each use, we moved to another interaction method.
2. Functionality iteration #2: Wireless microcontroller
We then attempted a wireless version in which
users touch conductive materials in pre-
specified locations. We used custom built
microcontroller radio frequency identification
(RFID) tags with capacitive sensors, built into
the contact interfaces, over an array of RFID
antennas multiplexed to a single RFID reader
for each play surface and connected to an
Arduino. When a contact interface button is
pressed it changed its ID code to reflect its Figure 2. Second prototype using RFIDs.
state, while continuously sending the ID. When a ‘pressed’ code is read, the Arduino sent a
corresponding key code through Bluetooth to the tablet. The buttons each had a microcontroller,
an inductive loop, a resistor and a conductive surface. However, we soon realized that this iteration
was too complex and prone to error.
3. Functionality iteration #3: Conductive ink
We decided to use touch/pressure switches as the gaming
interface. We were excited by the possibility of using
conductive ink to create a small circuit in which to mount these
touch buttons. We used resistors in between the buttons as
voltage drop points to determine button press via Arduino
calibration. However, the conductive ink could not create a
sufficiently reliable circuit, so we continued to our final
functionality iteration (described below).
4. Physical design iterations
Figure 3. Conductive ink
As we decided how our device would work, we brainstormed as
to how it would look, so that it could be lightweight, positioned in a variety of ways, allow objects
to be attached to it, be usable on different surfaces, support the weight of a tablet, enable interaction
with a variety of body movements, and be easily stored. We brainstormed ideas that included a
folding posterboard display and a series of large Lego or Magnatile-like blocks. We decided that a
box-like design with folding panels that could be extended (somewhat like an old camping stove)
would be ideal, because all the
components could be stored
inside of it. We began with a
plexiglass box, to which we
attached lever lock and set-
angle position hinges and
acrylic panels, including a
support structure to allow it to
be positioned at different
angles. While this design was
low cost and prototyped
button position, it was
extremely heavy and bulky,
with brittle acrylic and a non-
closable lid. It had a large
footprint, as panels could not
slide in and out. We evaluated
low-cost commercially-
available cases and decided on Figure 4. The FITBoard
a case resembling the Pelican product (www.pelicancases.com) due to its sturdiness. We created
top folding panels using acrylic and friction hinges and bottom panels to slide in and out using
guide rails made from aluminum extrusions. This allowed for a portable box design. However, the
sliding mechanism was a little rough and part of the box needed to be cut out to accommodate it.
Description of Final Approach and Design (product photo)
Our final product, shown in Figure D, results from this iterative
experience.
Functionality: The conductive ink was replaced with protoboard
to which the push buttons and resistors were soldered. Connections
were made between buttons along the protoboard. This design al-
lowed for a reliable connection between the buttons, while still al-
Figure 5. FITBoard logo
lowing for secure mounting and a slim profile. It utilizes the resis-
tors from the Iteration 3 to create voltage drop points for each button, resulting in different values
on the analog input of the Arduino when different buttons are pressed. The Arduino works by
dedicating an analog input to each panel of buttons. The analog input for each panel is checked, to
see if the value on the pin indicates a button is pressed. If a button is pressed, the Arduino program
reports a letter, corresponding to the button pressed, over the serial connection to the Surface tablet.
If no button press is detected, the program sends a “0” over the serial connection to the Surface
tablet.
Design: We doubled the play space by adding 2 extra panels to the top and bottom. The top panels
are double-sided and fold out to keep the lid light, while the bottom panels slide for extra stability.
The middle panels sit below the sliding path so the device can be used with the bottom panels
extended or kept in. Each panel has 6 keys, activated by buttons. The button covers hinge from
one side, allowing the button switch to be activated regardless of where the panel covering it is
pressed. The panels also have removable Velcro covers to enable toys to be attached to keys to
provide a more sensory-stimulating touch surface. There are head and foot controls that can be
easily positioned to accommodate a variety of heights and user positions. Finally, the FITBoard
rests on a height adjustable desk on wheels to accommodate users of different height, and the desk
has an open front to be wheelchair accessible. It can be easily removed from the desk for use on
other surfaces. The Arduino is protected within a case and the wires to each panel are protected.
Toys, head and foot controls can be stored in a basket underneath the desk.
Game interaction: The FITBoard application is
displayed on a Microsoft Surface tablet, chosen
because it has a USB port for the Arduino to
communicate button press signals into the game.
The therapist signs in to the application, or creates
a new user profile, and then selects an existing
client or adds a new client. He/she then selects a
game to play from available game icons, each of
which has a brief description of the game. The user
then selects FITBoard component configuration
for each section: head buttons, top panels, bottom Figure 6. Game selection screen
panels, and foot pedals. This is done by selecting a
photo of the desired configuration. The user positions the FITBoard accordingly. Tapping the right
arrow key brings the user to the button assignment page where they can select the keys that will
be used to play the game. Unassigned keys are ignored during gameplay. The therapist can place
objects or other indicators (e.g. a colorful piece of felt or an up, down, left, or right arrow) on the
assigned keys if desired. Once at a game menu, settings such as game difficulty and time can be
altered in each game’s options menu, or the user can choose to simply continue with the previous
round’s settings. We are working on including the ability to save one or multiple different presets
for both FITBoard and game settings. Game play data is saved on the tablet and is uploaded to the
cloud periodically. We are also working on graphs that show user progress over time.
Games: The games are built in Unity3D and scripted in C#. We have built 5 games, with more
under development. The games target a variety of age/cognitive levels. For example, in the paint
splash game, the user paints a picture on the screen via key presses that activate different colors.
In another game, the user controls a ball to catch targets that are moving on the screen. Each game
incorporates visual and auditory effects and provides positive feedback to the user. Each game
provides score feedback and offers numerous difficulty/challenge levels. Currently, all games
operate with 4 different input types, each assignable to an arbitrary number of different inputs
methods and keys. We are working to include more variables/settings to manipulate game difficulty
or stimulus levels to further customize experiences for different clients.
Our product is a low-
cost rehabilitation tool for
movement skill practice. By
moving touch interfaces,
moving board positions, or
increasing game difficulty
parameters, parents or
therapists can progress
physical and/or cognitive
difficulty levels. The FITBoard
can help the child maintain a
sitting or standing position for Figure 7. Game icons
longer periods, supporting
participation in independent play and activities of daily living. It can promote functional arm reach
and hand grasp, sensory stimulation, postural control, muscle strengthening and endurance, fine
motor skills, eye-hand coordination, executive functioning and/or visual attention skills.
Outcome (Results of any outcomes testing and/or user feedback)
We have just completed construction and will soon begin user testing. We have 12 therapists at
Franciscan and 5 at Spaulding enrolled in our funded study. Our first goal is to Assess FITBoard
ease of use within children’s rehabilitation programs. We will use qualitative methods to
identify any usability challenges as therapists at Spaulding and Franciscan interact with the
FITBoard. Next, we will determine how FITBoard use addresses relevant therapeutic goals.
Therapists and parents will identify a functional goal and use the FITBoard during 1-3 intervention
sessions with the child to address the goal; therapists, parents and children, as able, will complete
standardized measures evaluating satisfaction, engagement and motivation. Finally, we will
identify factors that might facilitate or impede FITBoard use in these settings. We will
conduct interviews with children, parents and therapists to identify barriers and facilitators.
Cost (Cost to produce and expected pricing)
Cost to Produce/
Item
Expected Pricing
Tablet $500.00
Software
Unity 3D $0.00
 Arduino Mega $25.00
Circuit boards $18.00
Resistors $12.00
Button switches $12.00
Sockets $13.00
Electrical
AC adaptors $16.00
Ribbon cable $9.00
Wire stripper $9.00
USB cable $10.00
Misc. other $20.00
Case $60.00
Desk $200.00
Friction hinges $25.00
Hinges $100.00
Acrylic plastic $26.00
Hooks $5.00
Storage bag $15.00
Mechanical Foot switches $12.00
Head switches $15.00
80/20 t-slot rail $25.00
Copper tubing $31.00
3D printing $75.00
Velcro $20.00
Loc-line $20.00
Misc. other $50.00
TOTAL $1,323.00

Significance
The FITBoard is a novel technology that can be used to provide home or clinic-based physical or
occupational therapy. It can meet the needs of children with neuromotor and neuromuscular
impairments who require long-term home-based therapeutic activity programs. It integrates the
motivating attributes of virtual reality systems with the functional, touch-based sensory input of
traditional rehabilitation interventions. Low cost materials, ease of use, flexibility to address
different needs and potential to integrate with existing Windows applications and games signify
clear commercialization potential. The FITBoard combines digital and physical worlds and
allows therapists to track children’s progress and support their autonomy as they select games,
configurations, and toys to use to interact with their therapy activities. It’s low-cost, easily
customizable nature enables it to address differing needs over time. We expect these features to
support repeated practice for children requiring long-term, individualized interventions. Following
our usability trial, we will apply for further grant funding to make any changes to the FITBoard
identified by child, parent and therapist users. We will then undertake longer-term feasibility and
effectiveness research in home or school settings. Our ultimate goal is to partner with industry to
ensure an accessible, user-friendly, low-cost product that can be integrated into school, home, or
community programs to enhance practice dosage of functionally relevant movement skills and
improve quality of life for children and youth with disabilities.
Acknowledgements
We would like to thank our advisors, Dr. Danielle Levac, Dr. Waleed Meleis, and Helene Dumas
for their support of this project and for seeking out funding opportunities. We are grateful to the
Deborah Munroe Noonan Memorial Research Fund, administered by the Medical Foundation, for
funding our feasibility and usability testing process. We are also very grateful for funding from
Northeastern University’s Undergraduate Provost Research and Creative Endeavors Award and
financial support from Enabling Engineering.
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