Digital LOTCA

How to Evaluate Acquired Brain Injury using Technology

Cristian Cuerda

, Jose A. Gallud

, Ricardo Tesoriero

and Habib M. Fardoun

Research Institute of Informatics, UCLM, Albacete, Spain

Ahlia University, Bahrein

Keywords:

LOTCA, Occupational Therapy, Distributed Interfaces, API Rest, Cross Platform Development.

Abstract:

In this article, we are going to describe the solution proposed to help people with acquired brain damage,

consisting of a service-oriented application, which provides a platform in which different tests are used that

are used in the test battery of cognitive evaluations of occupational therapy of Loewenstein. This platform

allows the patient to perform the tests on a touch screen, while the therapist can observe the results of the test

in real time on a monitor.

1 INTRODUCTION

First, we are going to deﬁne what is the Brain Da-

mage Injury, and what is the current situation of this

type of brain injuries in the world. Acquired Brain

Injury (ABI) is the involvement of brain structures

in people who, having been born without any type of

brain injury, suffer at a later time in their lives, brain

injuries that cause an impairment of cognitive, emo-

tional, behavioral and/or physical functioning. This

injury is a major health problem, due to the high num-

ber of people affected (more than 400,000 in Spain),

the duration, severity and variety of sequelae. The

ABI represents the main cause of disability in adults

in developed countries (Cerebral Injury Association

of Navarra, 2014).

The causes by which this type of injury can be ge-

nerated are very varied, and include (Cerebral Injury

Association of Navarra, 2014):

• Cranioencephalic trauma: is the brain injury from

a trauma or blow. The most frequent causes are

trafﬁc accidents (in 80 % of cases), work acci-

dents and sports accidents.

• Stroke: cerebrovascular accidents are injuries re-

sulting from an interruption of the cerebral blood

ﬂow system, such as embolisms and thrombosis,

or cerebral hemorrhages, including ruptured aneu-

rysms, or malformations of the veins and arteries

that irrigate the brain.

• Anoxies or hypoxia: it is the absence or poor oxy-

genation of the brain during a certain time, which

causes the neuronal death of part of the brain tis-

sue.

• Brain tumors: both the tumor itself and the proce-

dures aimed at its elimination (surgery, radiation)

cause important damage to the surrounding brain

tissue.

• Other causes: iencephalitis of various etiologies,

which may be a consequence of infectious, viral,

or toxic poisoning processes.

In the Figure 1 we can see a graphic overview of the

incidence and prevalence of ABI in Spain.

The ABI can affect all areas of human functioning.

The affected area and therefore the deﬁcits presen-

ted by the affected person will depend on the type of

injury, the initial location and severity of the injury;

as well as the characteristics of each affected person

such as age, personality or abilities prior to the in-

jury. The sequels are grouped into four dimensions

that may or may not be present in the same person

(Red Menni of Cerebral Injury, 2015):

• Physical-motor deﬁcits: There may be alterations

in balance, inability to stand, inability to walk, li-

mitations in the movement of one or more limbs,

or even control of the trunk and head at rest.

• Cognitive deﬁcits: for example, deﬁcits in le-

arning and memory, attentional deﬁcits, lan-

guage alterations, alterations in formal thinking

(logical-deductive reasoning, problem solving,

abstraction) and alterations in the regulation of

proactive or targeted behavior (planning, initia-

tion and behavioral self-regulation).

Cuerda, C., Gallud, J., Tesoriero, R. and Fardoun, H.

Digital LOTCA - How to Evaluate Acquired Brain Injury using Technology.

DOI: 10.5220/0006940807730779

In Proceedings of the 13th International Conference on Software Technologies (ICSOFT 2018), pages 773-779

ISBN: 978-989-758-320-9

773

Figure 1: Incidence and prevalence of ABI in Spain.

• Alterations in communication: occur due to the

alteration of physical and cognitive abilities or the

combination thereof. In the case of physical alte-

rations, oral, written or comprehension expression

is affected. There are also language alterations

that produce the inability for oral expression or

comprehension, despite the fact that the physical-

motor system remains intact.

• Behavioral and/or Emotional Alterations: At the

same time that the cognitive alterations appear be-

havioral and/or emotional alterations associated

with changes of character or personality. The ori-

gin of behavioral alterations could be considered

in two ways: lack of inhibition, sometimes cau-

sing physically or verbally aggressive behaviors

or excessive inhibition or poor behavioral initia-

tive, in which the affected shows apathy not initi-

ating activities if not explicitly asked , he does not

enjoy the things that he used to enjoy so much,

he has a feeling of exhaustion and lethargy, and

on the emotional level he hardly expresses emoti-

ons. When an ABI occurs, there is a sudden break

with the occupational roles that the person played

until the time of injury. This usually causes that

suddenly, the person suffering a brain injury mo-

ves from a balanced and active occupational rea-

lity to a situation in which he becomes a passive

recipient of care. Then, as he recovers capacities,

he ﬁnds himself in a situation of signiﬁcant decre-

ase in the level of participation, being unable or

depending on help to perform a large number of

activities.

As indicated by (Spanish Federation of Cerebral In-

jury, 2014), in the process of rehabilitation of Acqui-

red Brain Injury it has ﬁve objectives:

• Evaluate the sequelae of brain damage and the dif-

ﬁculties they cause.

• Reeducate and compensate for the sequelae of

brain damage to reduce disability.

• Prevent future complications of the sequelae of

the ABI or of the brain injury itself.

• Enhance conserved skills.

• Promote social and family integration.

Our solution focuses on this ﬁrst stage of the re-

habilitation of brain injury, the evaluation of the se-

quels produced and the difﬁculties or deﬁcits that

these cause. For this, we have started from a tradi-

tional methodology in this area called LOTCA, and

we have created a digital platform that makes it easier

to diagnose and assess the therapist.

2 OCCUPATIONAL THERAPY IN

ACQUIRED BRAIN INJURY

Loewenstein’s Occupational Therapy Cognitive As-

sessment (LOTCA) (Katz N., 1989) battery of eva-

luation was developed as a technique used to mea-

sure basic cognitive abilities and visual perception in

adults with neurological disabilities. It provides an

in-depth evaluation of basic cognitive skills and it can

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be used for treatment planning and review of treat-

ment progress (McDermott, 2011). The LOTCA bat-

tery measures the basic cognitive abilities required for

daily functions including orientation, visual percep-

tion and psychomotor skills, problem solving abili-

ties and thought operations. The development of this

battery is based on information obtained from clinical

and neuropsychological experience and development

theories.

Usually, LOTCA is used in the initial stage of the

evaluation of patients, but it can be used to establish

therapeutic goals and review the cognitive status over

time (Annes G., 1996) (Zwecker M, 2002) The ori-

ginal version of LOTCA (Katz N., 1989) was deve-

loped to be used by individuals under 70 with neu-

rological dysfunction and was made up of 20 items

grouped into 4 areas: Orientation, (2 items), percep-

tion (6 items), visual-motor organization ( 7 items)

and thought operations (5 items).

Next, we will proceed to describe the characteris-

tics of the speciﬁc measurement of each one of the

aforementioned areas:

• Orientation: the tests in the area of orientation

evaluate the orientation of the individual in space

and time.

• Visual perception: tests in the area of visual per-

ception evaluate the individual’s ability to identify

images of everyday objects, objects photographed

from unusual angles, distinguish between supe-

rimposed ﬁgures and recognize spatial relations-

hips between objects.

• Spatial perception: the tests related to spatial per-

ception evaluate the ability of the individual to dif-

ferentiate between right and left, to determine the

spatial relationships between objects and himself.

• Motor praxis: the tests related to motor praxis eva-

luate the ability of individuals to imitate motor

actions, use objects and perform symbolic actions.

• Visuomotor organization: the tests related to the

visual-motor organization evaluate the ability of

the individual to copy geometric ﬁgures, repro-

duce a two-dimensional model, copy a design of a

colored block and a clean block design, reproduce

a puzzle, a complete task of a peg board and draw

a clock.

• Thought operations: thinking operations evaluate

the individual’s ability to complete tasks that in-

clude: ordering, categorizing and drawing geome-

tric sequences (Annes G., 1996).

These analyzes have been standardized for the Is-

raeli population (Annes G., 1996) (Cermak S. A.,

1995) and suitable for use in the populations of the

United States (Katz N., 1997). Regarding the evalua-

tion time, LOTCA and LOTCA-II take approximately

45 minutes, with a range that ranges between 30 and

90 minutes (Annes G., 1996) (Zwecker M, 2002).

Regarding the suitability of individuals, LOTCA

can be used with:

• Patients who have had a stroke, cardiovascular ac-

cident, stroke, stroke, cerebrovascular accident,

etc. (Bar-Haim Erez A., 2003)

• Elderly individuals with dementia (Bar-Haim

Erez A., 2003).

• Individuals with traumatic brain injuries (An-

nes G., 1996).

• Individuals with intellectual disabilities (Jang Y.,

2009) and mental illness (Josman N., 2006) can

also use it.

• An adapted version was developed for children

with learning difﬁculties (Josman N., 2010).

• Patients with aphasia (Jang Y., 2009).

3 ARCHITECTURE OF THE

SOLUTION

So far we have studied how technology can help diag-

nose and evaluate people with Acquired Brain Injury,

and what are the most common techniques used today.

Next, we will explain the solution we propose.

The proposed solution, brieﬂy explained, consists

of a client-server application, in which the therapist

can create a personalized session for his patient, in-

cluding data such as his name or the patient’s own.

This session contains a test of the battery proposed

by LOTCA, belonging to the area of operations of

thought.

If we performed this test in a traditional way, the

therapist would provide the patient with a set of cards

containing different geometrical shapes with different

colors, and the patient should group them according

to the pattern provided by the therapist.

To carry out this task, our solution proposes a dis-

tributed application, in which the patient will work on

a touch screen solving the test, while the therapist ob-

serves the results in real time on another screen that

will act as a monitor. In this test, the patient will be

shown a set of cards with geometrical ﬁgures of dif-

ferent colors.

There are six different types of ﬁgures, and each

of them is represented in three different colors, there

being a total of eighteen different cards. The patient

must group these cards according to the parameters

Digital LOTCA - How to Evaluate Acquired Brain Injury using Technology

775

indicated, which may be, for example, by colors, by

shape, repeating a previously given pattern, etc.

The therapist will observe in real time on his mo-

nitor how the patient moves the different cards on the

screen, allowing him to observe and analyze strange

behaviors that indicate that the patient suffers some

type of injury. In addition, he can also view statistical

information such as the total time the session has been

running.

To make this communication distributed between

the screen of the therapist and the patient possible, it

is necessary that there is a server that acts as an in-

termadiary and that collects all the data and proces-

ses them properly. This server, implemented using

Node.js, has a REST services layer and is connected

to a NoSQL database implemented in MongoDB, in

which the data is stored in the session. The server

is responsible for collecting the information that the

therapist introduces about the session he want to cre-

ate, processes them and generates the test, allowing

the patient to connect to that session. Once the pa-

tient connects, it collects all the movements of cards

that it makes, and making use of Web Sockets, sends

them in real time to the therapist’s monitor. In addi-

tion, the server is also responsible for storing all of

this data in the database, so that the information of a

certain session can be viewed at any time.

This can be done using the display module of the

application results. This module allows, given a spe-

ciﬁc session that has already been carried out, to visu-

alize which cards have been moved by the patient in a

speciﬁc time slot, showing their position of origin, the

path traveled and the ﬁnal position. The therapist can

modify that time frame to visualize which cards have

moved in different lengths of time. Figure 2 shows

the architecture of the application in a schematic way.

The reason for choosing Javascript and speciﬁ-

cally, Node.js to implement the server, is the high

performance provided by this technology in service-

based applications. Node.js uses an event loop (Event

Loop), which manages all asynchronous operations.

In case of needing a blocking operation, an asynchro-

nous request is sent to that Event Loop together with

a callback, and the server continues with the request

when it can. If we compare it with other technologies

such as PHP and Java, in which every new connection

to the server generates a new thread, with its corre-

sponding memory consumption, Node.js for each new

connection to the server, creates a new event inside

the main engine of Node.js. This translates into great

memory savings and therefore, support for a larger

number of simultaneous requests using fewer resour-

ces. In addition, another of the great advantages is

the ease and speed of implementation and execution

Figure 2: View of the architecture of the application.

of unit tests.

The fact of choosing a NoSQL database like Mon-

goDB is fundamentally due to the advantages that this

type of database provides in matters of performance

and scalability with respect to a SQL database. In the

developed application, we do not work with sensitive

data about patients and, in particular, with data related

to their medical ﬁle, which according to Spanish le-

gislation are considered specially protected data. The-

refore, the solution adopted does not require extre-

mely restrictive measures regarding the storage and

processing of data, although it does use encryption in

those data that may lead to the theft of user informa-

tion.

4 WORKING WITH THE

DIGITAL LOTCA

To ﬁnish, we will show how the application we have

developed works. First, we will show the functioning

of the therapist’s interface. To access it, the therapist

must enter the application (see Figure 3) and select

the option ”I am the therapist”. Once this is done, the

therapist’s interface will be displayed.

From this interface, the therapist can create a new

session or can visualize information about a session

that he has already done previously. If the therapist

wishes to create a new session, he must enter an iden-

tiﬁer for that session if he wish (although one is pro-

vided automatically), his name and that of the patient

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Figure 3: Main user interface selection menu.

Figure 4: Menu to create a new session.

who is going to perform the session, as shown in the

Figure 4. Once the session is created, an interface will

be displayed in which the patient’s screen is included,

which will be shown empty until the patient enters the

session, and a lateral menu in which the cards can be

shufﬂed in case the order in the one that appears is not

the right one, end the session, or handle the chrono-

meter that measures the times of the session, as seen

in the Figure5.

Figure 5: The therapist’s interface before the patient enters.

Once this is done, the patient accesses the session

that has been created. To do this, hr must select the

option ”I am the patient” in the main application menu

(Figure 3). Then, he must enter the identiﬁer of the

session that the therapist chose when creating the ses-

sion (Figure 6)

When the patient joins the session, only the set of

cards necessary to complete the session will be shown

on the screen. When working with a touch screen,

he can freely drag those cards to group them follo-

wing the pattern proposed by the therapist based on

Figure 6: Menu to join a session.

Figure 7: Patient interface when joining the session.

the LOTCA test (Figure 7).

In the therapist’s interface, the patient’s screen is

now displayed, and each movement of cards that he

makes can be seen in real time from the therapist’s

interface, as shown in the 8.

Figure 8: The therapist interface when the patient joins the

session.

On the other hand, the therapist is offered the op-

tion of viewing information about previous sessions.

To do this, he must ﬁrst enter the identiﬁer of the ses-

sion he wants to view, as shown in the Figure 9.

When he has entered the identiﬁer, a visuali-

zer will be displayed where the therapist can scroll

through the bar that appears at the bottom of the

screen for the different moments of time the session

has. On the right side, he can edit the time slot over

which information is displayed, expressed in seconds.

For example, if the therapist moves with the lower bar

to position 20 and in the menu on the right, selects a

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Figure 9: The therapist interface when the patient joins the

session.

step of 5 seconds, the system will show information

about the position occupied by the cards in the second

20 of the session, and about the changes that they have

suffered in the last 5 seconds. For the id, the system

shows highlighted the cards that have moved in that

time slot, while the cards that have not moved, are

shown with a weaker color. In addition, the trajec-

tory followed by the cards displaced in that time slot,

their original position (using a card with the grated

contour) and their ﬁnal position (using a card with the

solid outline), as shown in the ﬁgure 10.

Figure 10: Session history viewer interface.

5 CONCLUSIONS

As a summary, we can say that our solution allows di-

gitizing and computerizing a set of tests proposed in

the LOTCA methodology for the diagnosis and eva-

luation of people with acquired brain damage.

Our solution allows the patient to work in a similar

way to the one he would do if he worked in a tradi-

tional way, by providing him with a touch screen in

which he can drag and move freely the cards used in

the test.

In addition, our solution allows the therapist to vi-

sualize at all times what movements the patient is per-

forming, without directly interfering with their task,

since they can visualize these movements in a moni-

tor that can be found anywhere. This allows that even

other therapists can visualize that session in real time,

even if they are not physically next to the patient.

The display module of old sessions allows the

therapist to access at any time the information of the

sessions, sharing this information with other collea-

gues who were not present at the time of the test, or re-

turning to analyze the movements that the patient has

made, in order to detect other anomalies that could

not be detected in real time.

Finally, we believe that this platform can conti-

nue to grow, implementing all the tests included in

LOTCA, and thus be able to replace the laborious tra-

ditional tests with these digitized tests.

REFERENCES

Annes G., Katz N., C. S. (1996). Comparison of younger

and older healthy american adults on the loewenstein

occupational therapy cognitive assessment. Occupati-

onal Therapy International, 3:157–173.

Bar-Haim Erez A., K. N. (2003). Cognitive proﬁles of indi-

viduals with dementia and healthy elderly: The loe-

wenstein occupational therapy cognitive assessment

(lotca-g). Physical and Occupational Therapy in Ge-

riatrics, 22:29–42.

Cerebral Injury Association of Navarra (2014).

https://www.adacen.org/blog/index.php/que-es-

el-dano-cerebral-y-cuales-son-sus-secuelas/.

Cermak S. A., Katz N., M. E. G. S. P. C. F. V. (1995). Per-

formance of americans and israelis with cerebrovascu-

lar accident on the loewenstein occupational therapy

cognitive assessment. American Journal of Occupati-

onal Therapy, 49:500– 506.

Jang Y., Chern J-S., L. K.-C. (2009). Validity of the loe-

wenstein occupational therapy cognitive assessment

in people with intellectual disabilities. American Jour-

nal of Occupational Therapy, 63:414–244.

Josman N., Abdallah T. M., E.-Y. B. (2010). Cultural factors

affecting the differential performance of israeli and

palestinian children on the loewenstein occupational

therapy cognitive assessment. Research in Develop-

mental Disabilities, 31:656–663.

Josman N., K. N. (2006). Relationships of categorization

on tests and daily tasks in patients with schizophrenia,

post-stroke patients and healthy controls. Psychiatry

Research, 141:15–28.

Katz N., Itzkovich M., A. S.-E. B. (1989). Loewenstein

occupational therapy cognitive assessment (lotca) bat-

tery for brain-injured patients: Reliability and validity.

American Journal of Occupational Therapy, 43:184–

192.

Katz N., Champagne D., C. S. (1997). Comparison of the

performance of younger and older adults on three ver-

sions of a puzzle reproduction task. American Journal

of Occupational Therapy, 51:562–568.

McDermott, A. (2011). Loewenstein Occupational Ther-

aphy Cognitive Assessment. Nicol Korner-Bitensky.

Red Menni of Cerebral Injury (2015). http://xn–

IDEE 2018 - Special Session on Interaction Design in Educational Environments

778

daocerebral-2db.es/papel-de-la-terapia-ocupacional-

en-la-rehabilitacion-del-dano-cerebral/.

Spanish Federation of Cerebral Injury (2014).

https://fedace.org/talleres-dano-cerebral.html.

Zwecker M, Levenkrohn S., F. Y.-Z. G. O. A. A. A. (2002).

Mini-mental state examination, cognitive ﬁm instru-

ment, and the loewenstein occupational therapy cog-

nitive assessment: Relation to functional outcome of

stroke patients. Archives of Physical Medicine and

Rehabilitation, 83:342–5.

Digital LOTCA - How to Evaluate Acquired Brain Injury using Technology

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