Systematic Review Chart

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CEREBRAL PALSY AND EYE-GAZE TECHNOLOGY. INTERACTION, PERSPECTIVE AND USABILITY. A REVIEW

1, RALUCA- 2, IONELA MANIU3 4

1,3,4Research and Telemedicine Center in Neurological Diseases in Children, Pediatric Clinical Hospital Sibiu, 2,3,4 of Sibiu

Keywords: augmentative and alternative communication (AAC), cerebral palsy, eye- tracking, text-to- speech, assistive technology (AT)

Abstract: The perspective of our review evaluated the interaction of cerebral palsy with eye-gaze interaction, the main tool of assistive technology, supporting communication and personal development for degrees of disability that involve motor impairment. Purpose: Bringing in the main field, alternative possibilities from the literature for better integration of the disabled. Methods: Systematic review. Results: We revealed the substantial impact of assistive technology on cerebral palsy patients, grade of

reduce the level of abandonment. Conclusion: Primordial eye-gaze interaction initiated the idea of infrared eye-trackers for better solutions in the field of communication, personal interaction with others, personal development and even employment. The eye-tracking industry has its popularity cost- depending, for the present, being in the range of expensive for disabled people. For cerebral palsy, eye- gaze has little steps, but with a crucial impact on quality of life.

4Corresponding author: -4, Sibiu, România, E-mail: [email protected], Phone: +40773 994375 Article received on 13.10.2017 and accepted for publication on 29.11.2017 ACTA MEDICA TRANSILVANICA December 2017;22(4):59-62

INTRODUCTION Cerebral palsy according to an accepted report in

2007 is the most c disorder, of the development of movement and posture, causing activity limitation, that are attributed to non-progressive disturbances that occurred in the developing fatal or infant

(1) It is not a disease in the traditional sense, but describes a clinical aspect of children who share the aspects non-progressive brain injury, lesion acquired ante-, perinatal or

limitation in activities, because of the motor disorders, accompanied by disturbances of communication, coordination, sensation, perception, cognition, behaviour, epilepsy, musculoskeletal and respiratory problems. All these factors and distribution classify cerebral palsy as a functional disability.

Reaching the needs of disabled people especially those with cerebral palsy is not a resource-full domain. It involves however several outstanding technologies but with a high-cost making it hard to get. So the situation is challenging.(2)

The management main goals in of cerebral palsy are

their mobility, reducing spasticity, hypertonia, speech therapy for better communication, physiotherapy for scoliosis and respiratory deficiencies because of musculoskeletal problems and other co-morbidities. In the multidisciplinary part we must take action and consider the rapid evolution of technology, especially assistive technology. Tools like wheelchairs/electric wheelchairs, AAC technology, Text-to-speech devices, were highlighted in our review, the actual resources in the literature.

PURPOSE

Our systematic approach brings some insights on cerebral palsy clinical picture and management plan from a technological point of view. In particular it describes how an everyday computer could be enhanced with the novelty of

technology in eye tracking materials, software and hardware that could build a new future of communicating through AAC and text-to-speech devices for disabled persons. It could be a convenient and an affordable solution in a country with a low income per person in which even a medium wage family

communicating, especially through eye-gaze. To this goal, we made the review of disease prevalence and clinical aspects with a focus of available devices of the past years in the context of communication, learning, expressing feelings, desires and basic needs.

MATERIALS AND METHODS The systematic review brought in front the usability of eye-gaze devices with infrared, AAC (augmentative and alternative technology), text-to-speech solutions and other manageable assistive technology for cerebral palsy patients mostly, but with the inclusion of its applicability to other motor impairments.

The literature that was studied is from PubMed Central, PubMed, Science Direct, Scopus, Springer, Google Schoolar, Mendeley, Sage Journals, The Lancet Journals, Hindawi, Wiley Online Library, Biomedcentral and we identified over 30 articles on eye tracking, assistive technology, augmentative and alternative communication alternatives, eye- gaze interaction, cerebral palsy, text-to-speech device

RESULTS Most of the authors present cerebral palsy life

expectancy to be dependent on the frequency and complication of comorbidities; a majority of people with severe comorbidities live to adult life.(3)

The prevalence is 2,1 of 1000 new-borns(4) and an estimated 17 million people are affected worldwide.

The incriminated etiologies of cerebral lesions are the

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following: a) during pregnancy or at birth - prematurity + low

weight; intrauterine infections with rubella, cytomegalovirus, toxoplasmosis (agents causing chorioamniotitis); cranial-frontal presentation of the fetus; hypoxia at birth due to prolonged labor; congenital cranial malformations; alcohol / drug use, thyroid hormones and estrogen.

b) at birth or early life: prolonged jaundice, gas poisoning (methyl mercury, carbon monoxide, butane), cerebral tumors, hypoxia, thrombophilia.(2,5)

The clinical manifestations include movement disorder, dysfunctional abilities and several other limitations of different parts of the body. In the present there is no known cure, only several clinical relieves, symptomatic interventions and managerial therapy with multidisciplinary participation.

The motor types of cerebral palsy are: 1) spastic (85- 91%); 2) dyskinetic (4-7%), including dystonia and athetosis; - 3) ataxic (4-6%), 4) hypotonic (2%).(6)

By topography of affected cerebral territory we have a categorization by:

a) Spastic with hemiplegia (38%), diplegia (37%) and quadriplegia (24%)

b) Dyskinetic, ataxic and hypotonic affects all limbs which makes it quadriplegic.(6)

Regarding the therapy, there is a zealous implication in stem-cell therapy for a near-future.(7,8) There is also an example given by Graham et al. 2016 (2) about magnesium sulphate administration during premature labour and also applying cooling to high-risk infants with a result in reducing the rate and severity of cerebral palsy.

Medical invasive treatment for some of the affections involve, Botulin toxin, Baclofen injections for spasticity, dystonia, benzodiazepines (Diazepam) for muscle relaxation and as hypnotic, surgery for articular luxation, physiotherapy for spasticity, vertebral affections, mobility and other comorbidities.(2)

The results of several studies showed improvement in eye gaze and AAC performance for patients with physical impairments, bringing a plus to communication, creativity and unlocking cognitive potentials.(9,10,11,12) With user-friendly grids (like Grid 3 - free source), children were helped to reduce restrictions of their activities and adult patients could express their own wishes and could speak to their surrounding caregivers in a convenient manner, helping to integrate a new way of education through eye technology. In the case of cerebral palsy, most of the authors put in front strabismus and epilepsy, their subject of medical integration with AAC being almost manageable without any interference with the eye- possible explanation resides in the fact that eye-gaze can focus only on the physiological eye, eliminating the fear of refusal.(8)

The principle of how eye-tracking works is not complicated, there is an infrared device, with a camera that detects and tracks the eye movements by an algorithm which implies pupillary (black or white) and corneal reflection,

choice of device, either in front of the computer with the eye tracker mounted underneath it or with the user having the eye trackers attached to eyeglasses.(13,10,14)

The experience in integration of cerebral palsy and infrared eye-tracking technology is important. There is a direct proportion in the communication between capable personnel, care-givers and users of technology, to ensure that patients interact with eye-gaze AAC devices and adapt to the way they want to express their thoughts. Participation on activities made a

huge difference in integration (15), with the attention on disappointment and abandonment.(16,17,18) Figure no. 1. Example of a basic eye-tracker mounted under the monitor

Figure no. 2. Example of a basic eye-tracker mounted on eyeglasses

Eye tackers, as an example, can be built from a simple web-cam and photodiodes, a pair of eyeglasses frames and by connecting to a computer via ITU GazeTracker Software, a freeware(19) Or they can be built under or integrated in a monitor/tablet with licenced software for the best data exchange between patient and device.(20,10)

DISCUSSIONS The way eye tracking helps and facilitates speech and

motor control is a thing of the future, still in development and an act of integration for patients and caregivers. Access technologies for communication started from a simpler and slower task (which takes minutes for only one word) like the E- tran boards. There were also apps built from the same principle, for phones to speak in pairs of words which mimic the same principle as E-tran.(21) There was an imperious need for a pathway of signal processing and AAC holistic system for better speech and writing with a solution found in eye-gaze tracking(11) So, based on the same principle of eye tracking with gaze physical boards and on the principles of Purkinje eye reflections, took birth infrared technology and researches that reached the state of great tracking of eye-movements, saccades and metrics.(22,23,24,25,26,14) The eye tracking technology

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became an on-screen grid, text-to-speech device which you could use to write words, phrases on the computer and a speaking synthetized voice would help the speech impaired patient to talk correctly or completely, depending on his disabilities (dysarthria, aphonia). The technology is not all body positioning dependent, there are a lot of possibilities and it is available in eyeglasses mounting, monitor/tablet attached, for

device can be mounted on the wheelchair or on the bed.(27,11) For example in a patient with tetraplegia because of a

cervical spine lesion could easily use a low-cost eye-tracker -levelled with an arm-

mount device over him.(28,29,30,31) In our review, we noticed that on gaze-based

technology spastic and diskinetic patients had great interaction with monitor/tablet mounted eye-trackers (desktop mounted).(10) There are a wide spectrum of devices for patients, from symbol-grid systems with text-to-speech to minimalistic games for toddlers and patients who can execute simple tasks, (11,30) and to read.(20) We should acknowledge the potential of Brain Computer Interface (BCI), which can be adjusted with an eye tracker or work individually.(32) The BCI is a non-invasive next-step in thought expressing, with the principle of EEG interpreting, it is developed to perceive intentions via brain wave-length, deducting and converting into simple commands on a computer. Adjusting this kind of technology with eye- tracking could simplify many tasks for the disabled and help them be more independent.(33,32,34,35) One of the limitations of the eye-gaze devices is the price range, even though eye tracking is well adapted for disabled children and adults and there are defects on accuracy and sampling rate of gazing,(36,10,14) for low-cost eye-trackers (<60Hz). The main marketed devices (middle and high-priced) for disabled have integrated environment control and algorithm for diskinetic movements. Another limitation is the level of interaction and support from trained personnel, teachers, parents, caregivers and patients which brings discrepancy in the best result for the one who needs it the most, the patient.(18) There are a lot of people from Romania who could benefit from AAC technology, it depends on the institutionalisation of patients, their needs and possible benefits. A recent study from last year in UK, showed that 536 of 100.000 need AAC equipment and health support.(37) Showing the high prevalence of people needing technology to have an attenuated to normalised life.

CONCLUSIONS Cerebral palsy seems like a hope-amputee for many of the patients and those who become their personal assistant for life, but that is not the case, especially in the era of technology,

personal development, makes eye-gaze technology one of the best potentials in communicating and letting the patient feel more independent.

Eye-tracking, even that it has a decade and a half of studies, still holds a grand potential in bringing assistive

- access to the disabled population, this is a thing to keep in mind and to bring it in front, to sensitise the people and leaders who can bring the best plan of financial support. By the proofs of the review and the potential that stands in eye-gaze technology many domains may benefit in the future, with eliminating the borders of human interaction and purpose-giving life. People with disability could even apply for full integrated jobs, become artists or making their own business, using only eye-trackers.

Acknowledgement: This work has been conducted in the Pediatric

Clinic Hospital Sibiu, within Research and Telemedicine Center in Neurological Diseases in Children - CEFORATEN project (ID928 SMIS-CSNR 13605) financed by ANCSI with the grant number 432 / 21. 12. 2012 thru the Sectoral Operational Programme Increase of Economic Competitiveness .

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