| 4. In which ways is the initiative creative and innovative?
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A. Strategic Methodology
The team adopted “The Lean Startup” strategy when implementing PRoGS. It is a principled approach to new product development. The strategy steps taken were:
1. Create a prototype rapidly (minimum viable product)
2. Obtain ground feedback (from St. Luke’s Hospital (SLH) Physiotherapists) and understand the feedback
3. Apply the feedback and create the next prototype
4. Go back to step 1
Such design iterations enabled the team to gather results quickly and direct them to the right design direction. It also allowed them to develop a simple, workable design.
B. Stages of Project Implementation
Stage 1: Specification Drafting
a) Collaborated with SLH to derive the product specification.
b) SLH was selected based on its close proximity to ITE – College West. Both are located in the western part of Singapore. They are well-known for Stroke Rehabilitation.
Stage 2: Prototype Development
a) The technical team created a prototype rapidly (Minimum Viable Product) for SLH’s testing and feedback.
b) Upon receiving the test results and feedback, the team designed and developed the next prototype.
c) Steps a) and b) were repeated till the product was accepted by SLH and ready for the User Acceptance Test.
Stage 3: User Acceptance Test (UAT)
a) ITE conducted internal UATs, allowing the team to re-design and work on areas for improvement.
b) Once PRoGS passed the ITE internal UATs, SLH conducted their own UATs on the product.
c) When the product passed all UATs, the results were submitted to SLH's Medical Board for their approval to proceed with the Medical Trial.
d) Each UAT included the following procedures:
i. Functional test on each sub-modules: EMG reader, PC program and Glove.
ii. Stress test for 4 hours ensuring no bruises and abrasion on the tester's hand.
Stage 4: Medical Board Approval
Stage 5: Medical Trial
It took the team two years to complete stages one to four, after which the medical trial was conducted in 2012. More than 5 SLH stroke patients participated in the pilot medical trial, and three patients (after attrition) participated in the full 10 weeks of the medical trial.
Stage 6: Patenting
The patent rights allowed the team to obtain licensing agreements with commercial companies, like Xentiq Pte Ltd, to produce PRoGS.
C. Strategic Collaboration with SLH
The team engaged SLH’s physiotherapists as they had expert knowledge in stroke rehabilitation and first-hand experience working with stroke patients. By combining SLH’s physiotherapists’ knowledge, and the team’s expertise in Engineering, innovative solutions were quickly derived.
To connect with relevant stakeholders and develop a product best suited to the needs of the stroke patients, the team held frequent discussions with the SLH team and physiotherapists. Such meetings facilitated “The Lean Startup” strategy adopted by the team, allowing them to gather feedback on their prototype quickly, refine their design and progress to the next prototype.
D. Involving ITE Students and Interns
As ITE lecturers, the team believed that it was important for them to ‘walk the talk’ when teaching their students and provide them a learning environment as authentic to real-life circumstances as possible. As such, students are involved in the prototype design of PRoGS with the aim to strengthen their skills in the following:
a) Schematic Capture and PCB routing
b) Lead-free Microsoldering
c) PCB Rapid Prototyping
d) Troubleshooting
e) Firmware development and testing
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| 5. Who implemented the initiative and what is the size of the population affected by this initiative?
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A. Public Agencies and Health Care Institutions
1. St. Luke’s Hospital (SLH)
SLH supplied the target audience - stroke patients, to participate in the PRoGS medical trials, and its physiotherapists also played the role of experts to the team. The physiotherapists not only had knowledge on stroke rehabilitation, but also experience working with stroke patients. They could therefore understand difficulties faced by stroke patients and what would benefit them. By engaging these partners, it helped team members who had no first-hand experience working with stroke patients, develop a PRoGS design best catered to their needs.
2. SingHealth and Singapore General Hospital (SGH)
SingHealth and SGH, two national healthcare groups, provided a source of backing, credibility and support to this project. SingHealth expressed interest to participate in PRoGS medical trials, allowing more stroke patients and caregivers to benefit from this innovation. In addition, there were plans to collaborate with SGH to enhance PRoGS. The enhanced application can be scaled up to a wider range of limb disabilities, thus meeting the needs of more stroke patients.
3. Ministry of Education (MOE)
The ‘MOE Translational R&D and Innovation Fund’ helped launch this project. With its success, the project also received more funds to further improve PRoGS, facilitating its commercialisation and wider medical trials with SLH and SGH.
4. Institute of Technical Education (ITE)
To train ITE students in technical skills, they were involved in the PRoGS’ design. ITE’s Senior Management also assisted the team with procurement and employing medical trial physiotherapist and interns.
B. Private Sector
1. Xentiq Pte Ltd.
Xentiq Pte Ltd. had a licensed agreement to mass-produce PRoGS in the market. As a commercial company, they also provided insights to PRoGS’ design, ensuring that it will be as close as possible to the commercialised version at the end of the project.
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| 6. How was the strategy implemented and what resources were mobilized?
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A. Costs Associated with Initiative
1. Technical / Equipment Resources
The total budget estimated for ‘Equipment’ for the duration of 3 Fiscal Years (FYs), from FY2009 to FY2011, was $33,400. The items consisted of:
a. Computers
b. Force & Torque Meter
c. EMG System
d. Biokinetic Analysis System
e. Body Medical Models
f. Miscellaneous
2. Human Resources
The total budget estimated for ‘Expenditure of Manpower’ (EOM) for the duration of 3 Fiscal Years (FYs), from FY2009 to FY2011, was $338,920. Manpower category consisted of:
a. Visiting Collaborators
b. Student Allowance
c. Project Engineers
d. Project Officers
e. Interns
f. ITE Student (Final Year Project)
g. Therapist salary
h. Research staff
i. Project Manager
3. Other Operating Expenses
The total budget estimated for Other Operating Expenses (OOE) for the duration of 3 Fiscal Years (FY), from FY2009 to FY2011, was $68,800.
B. Project Funds
The project was funded by the ‘Ministry of Education (MOE) Translational R&D and Innovation Fund’, which aims to:
a. Enable new innovations which will improve or develop new products, processes and systems that generate economic payoffs;
b. Enable self-initiated applied research ideas to be developed to the point which demonstrates potential for product development or improvement that could attract industry funding;
c. Support the Polytechnics in building up capabilities beyond the few selected niche areas of Centres of Innovation (COIs);
d. Support the Polytechnics' and ITE's partnership with the industry, especially local SMEs, to augment technological capabilities;
e. Improve the overall quality of Polytechnic and ITE education by updating and developing staff expertise and providing realistic project work opportunities for students; and
f. Enhance the Polytechnics’ and ITE’s standing as innovative and world-class education institutions.
The MOE Translational R&D and Innovation Fund was the only source of funding for the PRoGS project.
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| 7. Who were the stakeholders involved in the design of the initiative and in its implementation?
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1. Shorter and Quicker Rehabilitation Time
Results from PRoGS medical trials showed that by the 4th week of treatment, patients demonstrated better recovery than conventional therapy. A positive effect on the upper limb recovery post-stroke in the sub-acute rehabilitation was also found. Based on Motricity Index (MI) scores, the patient who used PRoGS had a higher improvement score (11.1%) as compared to a patient who received conventional therapy (9.2%). The Motricity Index test scores are used for measuring strength of upper and lower extremities (i.e. fingers and toes). Similarly, there was a 10.6% improvement in the Fugl-Meyer Assessment (FMA) scores of the patient who used PRoGS as compared to a patient receiving conventional therapy (3.18%). The Fugl-Meyer Assessment scores are used for measuring motor recovery – assesses five domains namely Motor function, Sensory function, Balance, Joint Range and Joint Pain.
2. Increased Confidence and Psychological Well-Being
The burdens experienced by stroke patients can diminish their psychological well-being and impair recovery. The favourable PRoGS treatment results received by the patients in turn gave them greater confidence to continue with the treatment and live a better quality life. It gave stroke patients greater hopes of recovery amidst their difficulties. Increased confidence also help patients establish self-efficacy, which has been proven to be crucial for recovery as patients believe that they have control and are able to attain their goals.
3. Cost-Effectiveness
With the team’s innovative technology and design, PRoGS is successful in shortening rehabilitation time at a very low cost (less than S$1,000). As stroke patients are often burdened by rising healthcare costs and expensive treatment procedures, the affordable PRoGS treatment becomes a viable and attractive rehabilitation option for Singaporeans, especially those from low-income groups.
4. High Functionality Design
PRoGS was designed to be portable and easily managed by the users so that patients and caregivers can undergo rehabilitation at their own conveniences, without the supervision of a therapist. Beyond these, the team made efforts to design the gloves in such a way that it is safe and can be easily managed (i.e. use of rechargeable batteries, antimicrobial grade cloth easily sterilised by alcohol swipe and detachable cloth gloves which could be machine washed).
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| 8. What were the most successful outputs and why was the initiative effective?
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The ITE-CW team started out developing the PRoGS prototype from scratch. However, the initial phase of development proved challenging as they had no first-hand experience working with stroke patients. Considering the importance of having a user-centric design, the PRoGS team decided to engage SLH’s physiotherapists, who have the knowledge and experience working with stroke patients, to obtain feedback at various stages of the development of their prototype. The numerous refinements took up significant amount of time. However, with the guidance and feedback received, the team developed a rehabilitation tool which caters to the needs of many stroke patients, and helped make a difference to their lives.
To ensure that PRoGS is best designed for the users, the team also held regular meetings with stakeholders to discuss progress issues and make changes to PRoGS. As a result, the team members who are full-time teaching staff, had to find time outside the classroom to work on the project. To address this, the team established close communication ties between ITE’s Senior Management and collaborators, and in turn, gained their trust. The team secured financial support and approval from Senior Management and collaborators to push the research forward, which saved them a lot of time and resources. With strong support given by ITE Management, the team was also able to expand the project to partner SGH to enhance PRoGS.
Particularly, the team’s collaborative partnership with therapists in SLH played a key part in effectively evaluating the progress of PRoGS in assisting stroke patients and allow for refinements to the rehabilitative programme. PRoGs medical trials were conducted. In 2012, 5 patients participated in the pilot trial. Subsequently, 10 patients volunteered for the programme, with 3 SLH stroke patients completing the full 10 weeks. These patients were closely monitored by the physiotherapists for limb strength and motor recovery. A positive effect on the upper limb recovery post-stroke in the sub-acute rehabilitation was also found. The feedback attained from these trials were then used to inform refinements and redevelopments of PRoGS.
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| 9. What were the main obstacles encountered and how were they overcome?
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1. Overcoming the Lack of Relevant Expert Knowledge
The team only possessed the technical know-how and not the tacit knowledge, including detailed understanding of stroke patients’ care and rehabilitative needs, which comes with being a direct caregiver. Without the experience of working directly with stroke patients, the team had difficulties understanding the daily challenges that patients’ face. Therefore, the team initially struggled with designing the PRoGs prototype on their own. To better design a product which connects closely to the user, and best suits his/her needs, the team instead partnered healthcare experts in the field, effectively bringing together the knowledge of an engineer and a practitioner. As stroke patients rely heavily on their physiotherapists, they have acute and insightful knowledge of patients’ needs. Thus, this partnership allowed the project to move forward and directly cater to specific functional needs.
2. Overcoming High Attrition Rates
In the beginning of the PRoGS medical trial, more than 10 patients volunteered. However, attrition rate was high, and only 3 patients underwent the full 10 weeks. This challenge was overcome by taking time to understand the difficulties experienced by patients themselves and to anticipate issues which might surface when they participate in such medical trials :
a. While treatment was free, patients were not reimbursed for transportation. For low-income stroke patients who are in greatest need of this low-cost rehabilitation solution, this incidence of high transportation costs undermines the project’s fundamental intended beneficiaries.
b. Stroke patients are easily affected by (i) depression; (ii) family or career changes; (iii) other illness complications; and (iv) misinformed alternative treatments
It was essential for the team to ensure sufficient administrative preparations (e.g. transport or meal reimbursements etc.) and consider their physical and emotional stability, to prevent too many drop-outs before and during the trial, and yield more fruitful results.
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