Combined Clinic-Home Approach for Upper Limb Robotic Therapy After Stroke: A Pilot Study

Stroke survivors' experiences with home-based telerehabilitation using an assistive device to improve upper limb function: a qualitative study

PURPOSE

Patients in the chronic phase after stroke often lack the possibility to intensively train their upper limb function. Assistive devices can be a solution to training intensively at home. This qualitative study investigated stroke survivors' experiences regarding training using the hoMEcare aRm rehabiLItatioN (MERLIN) system, an assistive device and telecare platform. We investigated patients' perspectives regarding the home-based training with the MERLIN system, on the International Classification of Functioning, Disability and Health (ICF) domains and the facilitators and barriers of the MERLIN system.

METHODS

Eleven patients in the chronic phase of stroke who completed the MERLIN trial took part in semi-structured interviews. Interviews were analysed using the framework method.

RESULTS

Participants were in general positive about the device and the training. Several experienced positive effects on ICF body functions, such as joint range of motion and self-confidence. Some experienced improvements in activities, but not on participation level. Home training had advantages: flexibility in training time and duration and no need to travel. The major barriers were technical hard- and software issues and ergonomic complaints. A list of recommendations regarding assistive devices and home-based rehabilitation was created.

CONCLUSIONS

Homebased training using an assistive device was well received by stroke patients to train their upper limb function. Future device developers should take patients' feedback into account to overcome the barriers related to the introduction of new assistive devices at home. Our recommendations may be the first step to implementing patients' perspectives during the early stages of device development. Implications for rehabilitationTraining at home was a well-received and convenient solution to improve the upper limb functionBarriers regarding hard- and software and device ergonomics need to be addressed in future assistive devicesRecommendations are provided for more successful implementation of assistive devices and home-based telerehabilitation programs.

Exploring the Feasibility of Computer Vision for Detecting Post-Stroke Compensatory Movements

Compensatory movements are commonly observed post-stroke and can negatively affect long-term motor recovery. In this context, a system that monitors movement quality and provides feedback would be beneficial. In this study, we aimed to detect compensatory movements during seated reaching using a conventional tablet camera and an open-source markerless body pose tracking algorithm called MediaPipe [1]. We annotated compensatory movements of stroke patients per frame based on the comparison between the paretic and non-paretic arms. We trained a binary classification model using the XGBoost algorithm to detect compensatory movements, which showed an average accuracy of 0.92 (SD 0.07) in leave-one-trial-out cross-validation across four participants. Although we observed good model performance, we also encountered challenges such as missing landmarks and misalignment, when using MediaPipe Pose. This study highlights the feasibility of using near real-time compensatory movement detection with a simple camera system in stroke rehabilitation. More work is necessary to assess the generalizability of our approach across diverse groups of stroke survivors and fully implement near real-time compensatory movement detection on a mobile device.

Wrist EMG Improves Gesture Classification for Stroke Patients

Electromyography (EMG) is a popular human-machine interface for hand gesture control of assistive and rehabilitative technology. EMG can be used to estimate motor intent even when an individual cannot physically move due to weakness or paralysis. EMG is traditionally recorded from the extrinsic hand muscles located in the forearm. However, the wrist has become an increasingly attractive recording location for commercial applications as EMG sensors can be integrated into wrist-worn wearables (e.g., watches, bracelets). Here we explored the impact that recording EMG from the wrist, instead of the forearm, has on stroke patients with upper-limb hemiparesis. We show that EMG signal-to-noise ratio is significantly worse at the paretic wrist relative to the paretic forearm and non-paretic wrist. Despite this, we also show that the ability to classify hand gestures from EMG was significantly better at the paretic wrist relative to the paretic forearm. Our results also provide guidance as to the ideal gestures for each recording location. Namely, single-digit gestures appeared easiest to classify from both forearm and wrist EMG on the paretic side. These results suggest commercialization of wrist-worn EMG would benefit stroke patients by providing more accurate EMG control in a more widely adopted wearable formfactor.

Motor Control Changes after Utilizing Upper Extremity Myoelectric Powered Wearable Orthotics in Persons with Acute SCI

Following spinal cord injury (SCI), upper extremity (UE) weakness may impede one's ability to carry out activities of daily living (ADLs). Such a limitation drastically lowers a person's level of independence. Additionally, therapy and the field of assistive technology continue to place a strong premium on the restoration of UE motor function in patients with SCI. The main objective of this study was to assess the benefits of an UE myoelectric-powered wearable orthosis (MPWO) produced by MyoMo, Inc. (Boston, MA) on improving UE motor function in order to enhance ADLs and quality of life in individuals with subacute SCI. A 43-year-old man with subacute incomplete SCI (iSCI), American Spinal Injury Association (ASIA) Impairment Scale (AIS) C grade received 18 sessions (over a period of six weeks) of UE mobility therapy utilizing the MPWO. The MPWO was used to enhance active range of motion (AROM) of the hand and elbow, and associated muscle activations. After training with the MPWO, hand and elbow AROM and muscle activations were enhanced. These preliminary findings imply that UE-MPWO device-assisted rehabilitation may increase participants' UE activities, leading to improved function.Clinical Relevance- These preliminary findings from a person with iSCI in the subacute phase indicate that training with UE-MPWO assistive devices may enhance UE use during ADLs for people with muscle weakness but still having some residual voluntary muscle activation ability.

Protocol for a remote home-based upper extremity self-training program for community-dwelling individuals after stroke

Background

Half of all stroke survivors experience hemiparesis on the contralateral side, resulting in chronic upper extremity (UE) impairment. Remote rehabilitation is a promising approach to optimize the gains made in the clinic to maximize function and promote UE use at home. This paper describes the study protocol for a remote home-based UE self-training program.

Design

This was a feasibility study that used a convergent mixed methods approach.

Methods

We collected data on 15 community-dwelling individuals with UE hemiparesis after stroke. The study used motivational interviewing (MI) and ecological momentary assessments (EMA) to maximize engagement in a 4-week personalized UE self-training program. The study consisted of three phases: 1) training in MI for the interventionists 2) creating customized treatment plans using shared decision making, and 3) four weeks of UE self-training.

Measures and analysis

To evaluate feasibility, we will summarize recruitment and retention rates, intervention delivery, acceptance, adherence, and safety. Quantitative UE outcomes will measure change in UE status after the intervention (Fugl-Meyer Assessment, Motor Activity Log, Canadian Occupational Performance Measure, and bilateral magnitude ratio). Qualitative data (1:1 semi-structured interviews) will capture participants' perceptions and experience with the intervention. Quantitative and qualitative data will be integrated to gain a deeper understanding of the facilitators and barriers for engagement and adherence to UE self-training.

Conclusion

The results of this study will advance the scientific knowledge for use of MI and EMA as methods for enhancing adherence and engagement in UE self-training in stroke rehabilitation. The ultimate impact of this research will be to improve UE recovery for individuals with stroke transitioning back into community.

Clinical trials registration

NCT05032638.

Commercial device-based hand rehabilitation systems for stroke patients: State of the art and future prospects

Various hand rehabilitation systems have recently been developed for stroke patients, particularly commercial devices. Articles from 10 electronic databases from 2010 to 2022 were extracted to conduct a systematic review to explore the existing commercial training systems (hardware and software) and evaluate their clinical effectiveness. This review divided the rehabilitation equipment into contact and non-contact types. Game-based training protocols were further classified into two types: immersion and non-immersion. The results of the review indicated that the majority of the devices included were effective in improving hand function. Users who underwent rehabilitation training with these devices reported improvements in their hand function. Game-based training protocols were particularly appealing as they helped reduce boredom during rehabilitation training sessions. However, the review also identified some common technical drawbacks in the devices, particularly in non-contact devices, such as their vulnerability to the effects of light. Additionally, it was found that currently, there is no commercially available game-based training protocol that specifically targets hand rehabilitation. Given the ongoing COVID-19 pandemic, there is a need to develop safer non-contact rehabilitation equipment and more engaging training protocols for community and home-based rehabilitation. Additionally, the review suggests the need for revisions or the development of new clinical scales for hand rehabilitation evaluation that consider the current scenario, where in-person interactions might be limited.

Functional requirements of a mobile-based application for stroke self-management: A Delphi study

This study aimed to determine the functional requirements of a self-management mobile application for stroke survivors. For extracting the initial functional requirements, a literature review as well as interviews with 17 patients and caregivers were done. The results were analyzed using the content analysis method. The initial extracted requirements were then provided to the specialists by the Delphi technique to determine the final functional requirements. Content validity ratio (CVR) and content validity index (CVI) were calculated according to the Lawshe model. Criteria for item approval included CVR > 0.49 and CVI > 0.79. Finally, the approved items were turned into a five-point Likert scale questionnaire and were then provided to 53 experts and items with a mean score higher than 3.75 were approved. Functional requirements including creating a user account, educational material, support services, providing reminders and alerts for drugs administration and physician appointments, and rehabilitation exercises (to improve balance, upper and lower extremities rehabilitation, and activities of daily living (ADLs)) were approved. Most of the approved functional requirements were related to rehabilitation exercises for improving upper limb motor function. The experts did not approve the requirements for using splints and slings or the recommendation to take some medications.

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions

IMPORTANCE

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs.

OBJECTIVE

In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity.

DATA SOURCES

We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

FINDINGS

We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

Application of a myoelectric elbow flexion assist orthosis in adult traumatic brachial plexus injury: patient perspectives

BACKGROUND

Individuals with brachial plexus injuries (BPIs) can be prescribed assistive devices, including myoelectric elbow orthoses (MEOs), for rehabilitation or functional use after failed treatment for elbow flexion restoration. Although recent case studies indicate potential for clinical improvements after using an MEO after BPI, the patients' perspectives on such use are still unknown.

OBJECTIVE

To explore patient perspectives on the use of an MEO after surgical treatment for a traumatic BPI.

STUDY DESIGN

Qualitative using both a focus group and semistructured interviews.

METHODS

Patients with BPI that used an MEO were recruited. Five patients participated in an in-person focus group, whereas three patients participated in individual phone interviews. Themes that emerged from the focus group were compared against those that emerged from the personal interviews.

RESULTS

Feedback was grouped into three themes: device usage, hardware performance, and device design. Within each theme, positive elements, areas for improvement, and additional considerations emerged. Patients indicated a positive attitude toward using an MEO as a rehabilitation tool. They desired a streamlined, stronger device to support them and assist during activities of daily living.

CONCLUSIONS

For patients with BPI, a well-designed MEO that meets their needs could assist with rehabilitation and increase independence in daily activities. Continued patient engagement in the evaluation and development of both medical devices and treatment plans offers the best opportunity for improved outcomes that are important to the patient.

The Rehabilitation Effects of Myoelectric Powered Wearable Orthotics on Improving Upper Extremity Function in Persons with SCI

Upper extremity (UE) weakness and/or paralysis following spinal cord injury (SCI) can lead to a limited capacity to perform activities of daily living (ADL). Such disability significantly reduces an individual's level of independence. Further, restoration of UE motor function in people with SCI remains a high priority in rehabilitation and the field of assistive technology. The overall goal of this study was to evaluate the effects of a myoelectric-powered wearable orthosis (MPWO) manufactured by MyoMo, Inc. (Boston, MA) for UE movement assistance on ameliorating UE motor function in order to improve ADL and quality of life in people with SCI. Two male participants with chronic incomplete SCI (iSCI), a 75- and a 31-year-old with AIS D and B, respectively, underwent 18 sessions (over 6 weeks) of UE movement rehabilitation using the MPWO. Handgrip strength, active range of motion (AROM) of the hand, response time to initiate a movement, and muscles activations were examined before and after the rehabilitation training using the MPWO. The response time to initiate UE movements decreased, and handgrip strength and AROM improved after training with the MPWO. These preliminary data suggest that rehabilitation with the use of the UE-MPWO device could enhance the participants' UE activities that led to improved function.Clinical Relevance- These preliminary results from two individuals with iSCI suggest that training with UE-MPWO assistive devices may improve UE utilization during ADL for individuals with muscle weakness or paralysis but still possessing residual voluntary muscle activation capabilities.

Upper Extremity Functional Improvements in Persons with SCI Resulted from Daily Utilization of Myoelectric Powered Wearable Orthotics

Spinal cord injury (SCI) is a medically complex and life-disrupting condition. It is estimated that 17,700 new traumatic SCI cases are reported each year in the United States. Approximately half of those cases, involves paralysis, sensory loss, and impaired motor control in the upper extremity (UE) and lower extremities. Such impairments could affect the person's independence as well as their family members and caregiver. The limitation at the UE can significantly limit the general activities of daily living (ADL). The purpose of this paper is to determine the daily utilization effects on changing the handgrip AROM and handgrip forces before and after providing upper extremity in-clinic rehabilitation along with at-home utilization using an UE myoelectric powered wearable orthosis (UE-MPWO) in a person with incomplete spinal cord injury (iSCI). This device helps restore function to the weakened or paralyzed UE muscles. We demonstrate that the handgrip AROM and handgrip force improved after 6-weeks of training with the UE-MPWO. The overall goal of this study was to evaluate the effects of UE-MPWO (MyoPro) when utilized for in-clinic rehabilitation combined with at-home daily use in improving UE movement and function of people with iSCI.Clinical Relevance- The results of in-clinic rehabilitation combined with at-home daily utilization suggest that this UE-MPWO may improve UE function. The examined UE-MPWO could represent a relatively good example as a rehabilitation and assistive tool for persons with iSCI.

Usability, functionality, and efficacy of a custom myoelectric elbow-wrist-hand orthosis to assist elbow function in individuals with stroke

Introduction

After stroke, upper limb impairment affects independent performance of activities of daily living. We evaluated the usability, functionality, and efficacy of a myoelectric elbow-wrist-hand orthosis to provide support, limit unsafe motion, and enhance the functional motion of paralyzed or weak upper limbs.

Methods

Individuals with stroke participated in a single-session study to evaluate the device. Ability to activate the device was tested in supported and unsupported shoulder position, as well as the elbow range of motion, ability to maintain elbow position, and ability to lift and hold a range of weights while using the device.

Results

No adverse events were reported. 71% of users were able to operate the device in all three active myoelectric activation modes (Biceps, Triceps, Dual) during testing. Users were able to hold a range of wrist weights (0.5–2 lbs) for 10–120 seconds, with the largest percentage of participants able to hold weights with the device in Biceps Mode.

Conclusions

The myoelectric elbow-wrist-hand orthosis improved range of motion during use and was efficacious at remediating upper extremity impairment after stroke. All users could operate the device in at least one mode, and most could lift and hold weights representative of some everyday objects using the device.

Home Activity-based Interventions for the Neurologically Impaired Upper Extremity: A Scoping Review

Background:

Activity-based therapy (ABT) for the upper extremity (UE) enables neurologic recovery with tasks that are functional, intense, and highly repetitive. A large proportion of rehabilitation occurs in the home and there is a gap in literature on the application of ABT within the home. The objective of this scoping review was to describe ABT in the home-setting for the neurologically-impaired UE.

Methods:

A systematic scoping review included searches of: MEDLINE, CINAHL, Cochrane, and OTSeeker.

Results:

A systematic search yielded 51 final studies. About 61% of ABT studies were exclusively within the home, others included outpatient visits (37%). Telerehabilitation was used in 37% of the studies with live-video and store forward techniques equally represented. ABT supported by technology was used in 61% of studies. Dosing of intervention ranged from 7 to 120 hours, with a mean of 34.5 hours of practice. Adherence with intended dosing was reported in 27% of studies and subjects completed a mean of 86% of the intended practice time. Sixty-seven percent of studies reported some degree of practice without therapist supervision.

Conclusions:

The results showed wide variability in the intervention methods, dosing and technology used in homebased settings. The high rate of adherence with dosing is encouraging for the application of homebased neurologic UE interventions. This scoping review highlights feasibility of UE ABT within the home and need for further research.

Converging Robotic Technologies in Targeted Neural Rehabilitation: A Review of Emerging Solutions and Challenges

Recent advances in the field of neural rehabilitation, facilitated through technological innovation and improved neurophysiological knowledge of impaired motor control, have opened up new research directions. Such advances increase the relevance of existing interventions, as well as allow novel methodologies and technological synergies. New approaches attempt to partially overcome long-term disability caused by spinal cord injury, using either invasive bridging technologies or noninvasive human-machine interfaces. Muscular dystrophies benefit from electromyography and novel sensors that shed light on underlying neuromotor mechanisms in people with Duchenne. Novel wearable robotics devices are being tailored to specific patient populations, such as traumatic brain injury, stroke, and amputated individuals. In addition, developments in robot-assisted rehabilitation may enhance motor learning and generate movement repetitions by decoding the brain activity of patients during therapy. This is further facilitated by artificial intelligence algorithms coupled with faster electronics. The practical impact of integrating such technologies with neural rehabilitation treatment can be substantial. They can potentially empower nontechnically trained individuals-namely, family members and professional carers-to alter the programming of neural rehabilitation robotic setups, to actively get involved and intervene promptly at the point of care. This narrative review considers existing and emerging neural rehabilitation technologies through the perspective of replacing or restoring functions, enhancing, or improving natural neural output, as well as promoting or recruiting dormant neuroplasticity. Upon conclusion, we discuss the future directions for neural rehabilitation research, diagnosis, and treatment based on the discussed technologies and their major roadblocks. This future may eventually become possible through technological evolution and convergence of mutually beneficial technologies to create hybrid solutions.

DESIGN, DYNAMIC MODELING AND CONTROL OF WEARABLE FINGER ORTHOSIS

Human hands and fingers are of significant importance in people’s capacity to perform daily tasks (touching, feeling, holding, gripping, writing). However, about 1.5 million people around the world are suffering from injuries, muscle and neurological disorders, a loss of hand function, or a few fingers due to stroke. This paper focuses on newly developed finger orthotics, which is thin, adaptable to the length of each finger and low energy costs. The aim of the study is to design and control a new robotic orthosis using for daily rehabilitation therapy. Kinematic and dynamic analysis of orthosis was calculated and the joint regulation of orthosis was obtained. The Lagrange method was used to obtain dynamics, and the Denavit–Hartenberg (D–H) method was used for kinematic analysis of hand. In order to understand its behavior, the robotic finger orthotics model was simulated in MatLab/Simulink. The simulation results show that the efficiency and robustness of proportional integral derivative (PID) controller are appropriate for the use of robotic finger orthotics.

A Mechanized Pediatric Elbow Joint Powered by a De-Based Artificial Skeletal Muscle

To increase the acceptability of exoskeletons, there is growing attention toward finding an alternative soft actuator that can safely perform at close vicinity of the human body. In this study, we investigated the capability of the dielectric elastomer actuators (DEAs), for muscle-like actuation of rehabilitation robots. First, an artificial skeletal muscle was configured using commercially available stacked DEAs arranged in a 3x4 array of three parallel fibers consisting of four DEAs connected in series. The shortening and force generation capabilities of this artificial muscle were then measured. An alternate 3x5 version of this muscle was mounted on the forearm of an upper extremity phantom model to actuate its elbow joint. The actuation capability of this muscle was then tested under various tensile loads, 1 N to 4 N, placed at the center of mass of the forearm+hand of the phantom model. The active range of motion and angular velocity of the phantom model's tip of the hand were measured using a motion capture system. The 3×4 artificial muscle produced 30.47 N of force and 5.3 mm of maximum shortening. The 3x5 artificial muscle was capable of actuating the elbow flexion 19.5º with 16.2 º/s angular velocity in the sagittal plane, under a 1 N tensile load. The active range of motion was substantially reduced as the tensile loads increased, which limits the capability of these muscles in the current upper extremity exoskeleton design.

Rehabilitative and assistive wearable mechatronic upper-limb devices: A review

Recently, there has been a trend toward assistive mechatronic devices that are wearable. These devices provide the ability to assist without tethering the user to a specific location. However, there are characteristics of these devices that are limiting their ability to perform motion tasks and the adoption rate of these devices into clinical settings. The objective of this research is to perform a review of the existing wearable assistive devices that are used to assist with musculoskeletal and neurological disorders affecting the upper limb. A review of the existing literature was conducted on devices that are wearable, assistive, and mechatronic, and that provide motion assistance to the upper limb. Five areas were examined, including sensors, actuators, control techniques, computer systems, and intended applications. Fifty-three devices were reviewed that either assist with musculoskeletal disorders or suppress tremor. The general trends found in this review show a lack of requirements, device details, and standardization of reporting and evaluation. Two areas to accelerate the evolution of these devices were identified, including the standardization of research, clinical, and engineering details, and the promotion of multidisciplinary culture. Adoption of these devices into their intended application domains relies on the continued efforts of the community.

Use of a myoelectric upper limb orthosis for rehabilitation of the upper limb in traumatic brain injury: A case report

BACKGROUND

Upper limb motor deficits following traumatic brain injury are prevalent and effective therapies are needed. The purpose of this case report was to illustrate response to a novel therapy using a myoelectric orthosis in a person with TBI.Case description: A 42-year-old female, 29.5 years post-traumatic brain injury with diminished motor control/coordination, and learned nonuse of the right arm. She also had cognitive deficits and did not spontaneously use her right arm functionally.

INTERVENTION

Study included three phases: baseline data collection/device fabrication (five weeks); in-clinic training (2×/week for nine weeks); and home-use phase (nine weeks). The orthosis was incorporated into motor learning-based therapy.Outcomes: During in-clinic training, active range of motion, tone, muscle power, Fugl-Meyer, box and blocks test, and Chedoke assessment score improved. During the home-use phase, decrease in tone was maintained and all other outcomes declined but were still better upon study completion than baseline. The participant trained with the orthosis 70.12 h, logging over 13,000 repetitions of elbow flexion/extension and hand open/close.

DISCUSSION

Despite long-standing traumatic brain injury, meaningful improvements in motor function were observed and were likely the results of high repetition practice of functional movement delivered over a long duration. Further assessment in a larger cohort is warranted.

Robotics in Health Care: Perspectives of Robot-Aided Interventions in Clinical Practice for Rehabilitation of Upper Limbs

Robot-aided systems to support the physical rehabilitation of individuals with neurological impairment is one of the fields that has been widely developed in the last few decades. However, the adoption of these systems in clinical practice remains limited. In order to better understanding the causes of this limitation, a systematic review of robot-based systems focused on upper extremity rehabilitation is presented in this paper. A systematic search and review of related articles in the literature were conducted. The chosen works were analyzed according to the type of device, the data analysis capability, the therapy method, the human–robot interaction, the safety strategies, and the focus of treatment. As a conclusion, self-adaptation for personalizing the treatments, safeguarding and enhancing of patient–robot interaction towards training essential factors of movement generation into the same paradigm, or the use of lifelike environments in fully-immersive virtual reality for increasing the assimilation of motor gains could be relevant factors to develop more accepted robot-aided systems in clinical practice.

Home-based technologies for stroke rehabilitation: A systematic review

BACKGROUND

Many forms of home-based technology targeting stroke rehabilitation have been devised, and a number of human factors are important to their application, suggesting the need to examine this information in a comprehensive review.

OBJECTIVE

The systematic review aims to synthesize the current knowledge of technologies and human factors in home-based technologies for stroke rehabilitation.

METHODS

We conducted a systematic literature search in three electronic databases (IEEE, ACM, PubMed), including secondary citations from the literature search. We included articles that used technological means to help stroke patients conduct rehabilitation at home, reported empirical studies that evaluated the technologies with patients in the home environment, and were published in English. Three authors independently conducted the content analysis of searched articles using a list of interactively defined factors.

RESULTS

The search yielded 832 potentially relevant articles, leading to 31 articles that were included for in-depth analysis. The types of technology of reviewed articles included games, telerehabilitation, robotic devices, virtual reality devices, sensors, and tablets. We present the merits and limitations of each type of technology. We then derive two main human factors in designing home-based technologies for stroke rehabilitation: designing for engagement (including external and internal motivation) and designing for the home environment (including understanding the social context, practical challenges, and technical proficiency).

CONCLUSION

This systematic review presents an overview of key technologies and human factors for designing home-based technologies for stroke rehabilitation.

A Review of Robotics in Neurorehabilitation: Towards an Automated Process for Upper Limb

Robot-mediated neurorehabilitation is a growing field that seeks to incorporate advances in robotics combined with neuroscience and rehabilitation to define new methods for treating problems related with neurological diseases. In this paper, a systematic literature review is conducted to identify the contribution of robotics for upper limb neurorehabilitation, highlighting its relation with the rehabilitation cycle, and to clarify the prospective research directions in the development of more autonomous rehabilitation processes. With this aim, first, a study and definition of a general rehabilitation process are made, and then, it is particularized for the case of neurorehabilitation, identifying the components involved in the cycle and their degree of interaction between them. Next, this generic process is compared with the current literature in robotics focused on upper limb treatment, analyzing which components of this rehabilitation cycle are being investigated. Finally, the challenges and opportunities to obtain more autonomous rehabilitation processes are discussed. In addition, based on this study, a series of technical requirements that should be taken into account when designing and implementing autonomous robotic systems for rehabilitation is presented and discussed.

Simulation of variable impedance as an intervention for upper extremity motor exploration

Current methods in robot-assisted therapy are limited in providing predictions of the effectiveness of interventions. Our approach focuses on how robotic interaction can impact the distribution of movements expressed in the arm. Using data from a previous study with stroke survivors (n=10), we performed simulations to examine how changes in hand endpoint impedance would alter exploratory motion. We present methods for designing a custom training intervention, by relating the desired change in acceleration covariance in planar motion with a corresponding change in inertia matrix. We first characterized motor exploration in terms of overall covariance in acceleration, and secondly as covariance that varies with position in the workspace. Using a forward dynamics simulation of the hand endpoint impedance, we found that the variable change in endpoint inertia resulted in better recovery of acceleration covariance compared to the fixed change in inertia method. These results could significantly impact rehabilitation firstly in terms of design principles for altering coordination patterns through direct assistance. Furthermore, our work might serve to improve therapy by facilitating access to repeated practice of independent joint motion.

Implementation of a Surface Electromyography-Based Upper Extremity Exoskeleton Controller Using Learning from Demonstration

Upper-extremity exoskeletons have demonstrated potential as augmentative, assistive, and rehabilitative devices. Typical control of upper-extremity exoskeletons have relied on switches, force/torque sensors, and surface electromyography (sEMG), but these systems are usually reactionary, and/or rely on entirely hand-tuned parameters. sEMG-based systems may be able to provide anticipatory control, since they interface directly with muscle signals, but typically require expert placement of sensors on muscle bodies. We present an implementation of an adaptive sEMG-based exoskeleton controller that learns a mapping between muscle activation and the desired system state during interaction with a user, generating a personalized sEMG feature classifier to allow for anticipatory control. This system is robust to novice placement of sEMG sensors, as well as subdermal muscle shifts. We validate this method with 18 subjects using a thumb exoskeleton to complete a book-placement task. This learning-from-demonstration system for exoskeleton control allows for very short training times, as well as the potential for improvement in intent recognition over time, and adaptation to physiological changes in the user, such as those due to fatigue.

Hand Robotic Therapy in Children with Hemiparesis: A Pilot Study

OBJECTIVE

The aim of this study was to understand the impact of training with a hand robotic device on hand paresis and function in a population of children with hemiparesis.

METHODS

Twelve children with hemiparesis (mean age, 9 [SD, 3.64] years) completed participation in this prospective, experimental, pilot study. Participants underwent clinical assessments at baseline and again 6 weeks later with instructions to not initiate new therapies. After these assessments, participants received 6 weeks of training with a hand robotic device, consisting of 1-hour sessions, 3 times weekly. Assessments were repeated on completion of training.

RESULTS

Results showed significant improvements after training on the Assisting Hand Assessment (mean difference, 2.0 Assisting Hand Assessment units; P = 0.011) and on the upper-extremity component of the Fugl-Meyer scale (raw score mean difference, 4.334; P = 0.001). No significant improvements between pretest and posttest were noted on the Jebsen-Taylor Test of Hand Function, the Quality of Upper Extremity Skills Test, or the Pediatric Evaluation of Disability Inventory after intervention. Total active mobility of digits and grip strength also failed to demonstrate significant changes after training.

INTERPRETATION

Participants tolerated training with the hand robotic device, and significant improvements in bimanual hand use, as well as impairment-based scales, were noted. Improvements were carried over into bimanual skills during play.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand key components of neuroplasticity; (2) Discuss the benefits of robotic therapy in the recovery of hand function in pediatric patients with hemiplegia; and (3) Appropriately incorporate robotic therapy into the treatment plan of pediatric patients with hemiplegia.

LEVEL

Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Recommendations for the Implementation of Telehealth in Cardiovascular and Stroke Care: A Policy Statement From the American Heart Association

The aim of this policy statement is to provide a comprehensive review of the scientific evidence evaluating the use of telemedicine in cardiovascular and stroke care and to provide consensus policy suggestions. We evaluate the effectiveness of telehealth in advancing healthcare quality, identify legal and regulatory barriers that impede telehealth adoption or delivery, propose steps to overcome these barriers, and identify areas for future research to ensure that telehealth continues to enhance the quality of cardiovascular and stroke care. The result of these efforts is designed to promote telehealth models that ensure better patient access to high-quality cardiovascular and stroke care while striving for optimal protection of patient safety and privacy.

Giving Them a Hand: Wearing a Myoelectric Elbow-Wrist-Hand Orthosis Reduces Upper Extremity Impairment in Chronic Stroke

OBJECTIVE

To determine the immediate effect of a portable, myoelectric elbow-wrist-hand orthosis on paretic upper extremity (UE) impairment in chronic, stable, moderately impaired stroke survivors.

DESIGN

Observational cohort study.

SETTING

Outpatient rehabilitation clinic.

PARTICIPANTS

Participants exhibiting chronic, moderate, stable, poststroke, UE hemiparesis (N=18).

INTERVENTIONS

Subjects were administered a battery of measures testing UE impairment and function. They then donned a fabricated myoelectric elbow-wrist-hand orthosis and were again tested on the same battery of measures while wearing the device.

MAIN OUTCOME MEASURES

The primary outcome measure was the UE Section of the Fugl-Meyer Scale. Subjects were also administered a battery of functional tasks and the Box and Block (BB) test.

RESULTS

Subjects exhibited significantly reduced UE impairment while wearing the myoelectric elbow-wrist-hand orthosis (FM: t₁₇=8.56, P<.0001) and increased quality in performing all functional tasks while wearing the myoelectric elbow-wrist-hand orthosis, with 3 subtasks showing significant increases (feeding [grasp]: z=2.251, P=.024; feeding [elbow]: z=2.966, P=.003; drinking [grasp]: z=3.187, P=.001). Additionally, subjects showed significant decreases in time taken to grasp a cup (z=1.286, P=.016) and increased gross manual dexterity while wearing a myoelectric elbow-wrist-hand orthosis (BB test: z=3.42, P<.001).

CONCLUSIONS

Results suggest that UE impairment, as measured by the Fugl-Meyer Scale, is significantly reduced when donning a myoelectric elbow-wrist-hand orthosis, and these changes exceeded the Fugl-Meyer Scale's clinically important difference threshold. Further, utilization of a myoelectric elbow-wrist-hand orthosis significantly increased gross manual dexterity and performance of certain functional tasks. Future work will integrate education sessions to increase subjects' ability to perform multijoint functional movements and attain consistent functional changes.

Self-directed arm therapy at home after stroke with a sensor-based virtual reality training system

BACKGROUND

The effect of rehabilitative training after stroke is dose-dependent. Out-patient rehabilitation training is often limited by transport logistics, financial resources and a lack of motivation/compliance. We studied the feasibility of an unsupervised arm therapy for self-directed rehabilitation therapy in patients' homes.

METHODS

An open-label, single group study involving eleven patients with hemiparesis due to stroke (27 ± 31.5 months post-stroke) was conducted. The patients trained with an inertial measurement unit (IMU)-based virtual reality system (ArmeoSenso) in their homes for six weeks. The self-selected dose of training with ArmeoSenso was the principal outcome measure whereas the Fugl-Meyer Assessment of the upper extremity (FMA-UE), the Wolf Motor Function Test (WMFT) and IMU-derived kinematic metrics were used to assess arm function, training intensity and trunk movement. Repeated measures one-way ANOVAs were used to assess differences in training duration and clinical scores over time.

RESULTS

All subjects were able to use the system independently in their homes and no safety issues were reported. Patients trained on 26.5 ± 11.5 days out of 42 days for a duration of 137 ± 120 min per week. The weekly training duration did not change over the course of six weeks (p = 0.146). The arm function of these patients improved significantly by 4.1 points (p = 0.003) in the FMA-UE. Changes in the WMFT were not significant (p = 0.552). ArmeoSenso based metrics showed an improvement in arm function, a high number of reaching movements (387 per session), and minimal compensatory movements of the trunk while training.

CONCLUSIONS

Self-directed home therapy with an IMU-based home therapy system is safe and can provide a high dose of rehabilitative therapy. The assessments integrated into the system allow daily therapy monitoring, difficulty adaptation and detection of maladaptive motor patterns such as trunk movements during reaching.

TRIAL REGISTRATION

Unique identifier: NCT02098135 .