Understanding upper extremity home programs and the use of gaming technology for persons after stroke

Exergaming to Increase Physical Activity in Older Adults: Feasibility and Practical Implications

PURPOSE OF REVIEW

To evaluate the feasibility of exergaming among older adults, focusing on acceptability, demand, implementation, and practicality. Additionally, to offer practical implications based on the review's findings.

RECENT FINDINGS

Exergaming is a safe for older adults, potentially increasing physical activity, balance, cognition, and mood. Despite these possible benefits, barriers such as unfamiliarity with equipment, complex controls, and unclear instructions may challenge older adults in exergaming. Based on the experience of older adults, they found exergaming enjoyable, particularly the social interactions. Exergaming was perceived as physically and cognitively demanding, with technical and safety challenges. Introducing exergaming requires thorough familiarization, including written and video instructions, follow-up support, and home accessibility. To be able to follow improvements during exergaming as well as age-appropriate challenges are important for successful integration into daily life. Based on these findings, an ExerGameFlow model for older adults was developed which provides practical implications for future design of exergames and interventions.

Post-stroke hand gesture recognition via one-shot transfer learning using prototypical networks

BACKGROUND

In-home rehabilitation systems are a promising, potential alternative to conventional therapy for stroke survivors. Unfortunately, physiological differences between participants and sensor displacement in wearable sensors pose a significant challenge to classifier performance, particularly for people with stroke who may encounter difficulties repeatedly performing trials. This makes it challenging to create reliable in-home rehabilitation systems that can accurately classify gestures.

METHODS

Twenty individuals who suffered a stroke performed seven different gestures (mass flexion, mass extension, wrist volar flexion, wrist dorsiflexion, forearm pronation, forearm supination, and rest) related to activities of daily living. They performed these gestures while wearing EMG sensors on the forearm, as well as FMG sensors and an IMU on the wrist. We developed a model based on prototypical networks for one-shot transfer learning, K-Best feature selection, and increased window size to improve model accuracy. Our model was evaluated against conventional transfer learning with neural networks, as well as subject-dependent and subject-independent classifiers: neural networks, LGBM, LDA, and SVM.

RESULTS

Our proposed model achieved 82.2% hand-gesture classification accuracy, which was better (P<0.05) than one-shot transfer learning with neural networks (63.17%), neural networks (59.72%), LGBM (65.09%), LDA (63.35%), and SVM (54.5%). In addition, our model performed similarly to subject-dependent classifiers, slightly lower than SVM (83.84%) but higher than neural networks (81.62%), LGBM (80.79%), and LDA (74.89%). Using K-Best features improved the accuracy in 3 of the 6 classifiers used for evaluation, while not affecting the accuracy in the other classifiers. Increasing the window size improved the accuracy of all the classifiers by an average of 4.28%.

CONCLUSION

Our proposed model showed significant improvements in hand-gesture recognition accuracy in individuals who have had a stroke as compared with conventional transfer learning, neural networks and traditional machine learning approaches. In addition, K-Best feature selection and increased window size can further improve the accuracy. This approach could help to alleviate the impact of physiological differences and create a subject-independent model for stroke survivors that improves the classification accuracy of wearable sensors.

TRIAL REGISTRATION NUMBER

The study was registered in Chinese Clinical Trial Registry with registration number CHiCTR1800017568 in 2018/08/04.

Combining soft robotics and telerehabilitation for improving motor function after stroke

Telerehabilitation and robotics, either traditional rigid or soft, have been extensively studied and used to improve hand functionality after a stroke. However, a limited number of devices combined these two technologies to such a level of maturity that was possible to use them at the patients' home, unsupervised. Here we present a novel investigation that demonstrates the feasibility of a system that integrates a soft inflatable robotic glove, a cloud-connected software interface, and a telerehabilitation therapy. Ten chronic moderate-to-severe stroke survivors independently used the system at their home for 4 weeks, following a software-led therapy and being in touch with occupational therapists. Data from the therapy, including automatic assessments by the robot, were available to the occupational therapists in real-time, thanks to the cloud-connected capability of the system. The participants used the system intensively (about five times more movements per session than the standard care) for a total of more than 8 hr of therapy on average. We were able to observe improvements in standard clinical metrics (FMA +3.9 ± 4.0, p < .05, COPM-P + 2.5 ± 1.3, p < .05, COPM-S + 2.6 ± 1.9, p < .05, MAL-AOU +6.6 ± 6.5, p < .05) and range of motion (+88%) at the end of the intervention. Despite being small, these improvements sustained at follow-up, 2 weeks after the end of the therapy. These promising results pave the way toward further investigation for the deployment of combined soft robotic/telerehabilitive systems at-home for autonomous usage for stroke rehabilitation.

The use of home-based digital technology to support post-stroke upper limb rehabilitation: A scoping review

OBJECTIVE

To identify, map and synthesize the extent and nature of existing studies on the use of home-based digital technology to support post-stroke upper limb rehabilitation.

DATA SOURCES

A comprehensive literature search was completed between 30 May 2022 and 05 April 2023, from seven online databases (CINAHL, Cochrane Library, PubMed, ScienceDirect, IEEExplore, Web of Science and PEDro), Google Scholar and the reference lists of already identified articles.

METHODS

A scoping review was conducted according to Arksey and O'Malley (2005), and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. All English-language studies reporting on the use of home-based digital technology to support upper limb post-stroke rehabilitation were eligible for inclusion.

RESULTS

The search generated a total of 1895 records, of which 76 articles met the inclusion criteria. Of these, 52 were experimental studies and the rest, qualitative, case series and case studies. Of the overall 2149 participants, 2028 were stroke survivors with upper limb impairment. The majority of studies were aimed at developing, designing and/or assessing the feasibility, acceptability and efficacy of a digital system for poststroke upper limb rehabilitation in home settings. The thematic analysis found six major categories: Tele-rehabilitation (n = 29), games (n = 45), virtual reality (n = 26), sensor (n = 22), mobile technology (n = 22), and robotics (n = 8).

CONCLUSION

The digital technologies used in post-stroke upper limb rehabilitation were multimodal, and system-based comprising telerehabilitation, gamification, virtual reality, mobile technology, sensors and robotics. Furthermore, future research should focus to determine the effectiveness of these modalities.

SmartWear body sensors for neurological and neurosurgical patients: A review of current and future technologies

Background/objective

Recent technological advances have allowed for the development of smart wearable devices (SmartWear) which can be used to monitor various aspects of patient healthcare. These devices provide clinicians with continuous biometric data collection for patients in both inpatient and outpatient settings. Although these devices have been widely used in fields such as cardiology and orthopedics, their use in the field of neurosurgery and neurology remains in its infancy.

Methods

A comprehensive literature search for the current and future applications of SmartWear devices in the above conditions was conducted, focusing on outpatient monitoring.

Findings

Through the integration of sensors which measure parameters such as physical activity, hemodynamic variables, and electrical conductivity - these devices have been applied to patient populations such as those at risk for stroke, suffering from epilepsy, with neurodegenerative disease, with spinal cord injury and/or recovering from neurosurgical procedures. Further, these devices are being tested in various clinical trials and there is a demonstrated interest in the development of new technologies.

Conclusion

This review provides an in-depth evaluation of the use of SmartWear in selected neurological diseases and neurosurgical applications. It is clear that these devices have demonstrated efficacy in a variety of neurological and neurosurgical applications, however challenges such as data privacy and management must be addressed.

An analysis of clinical outcomes and essential parameters for designing effective games for upper limb rehabilitation: A scoping review

Background and Aims

Upper limb disabilities are one of the most common disabilities among different groups of people who always need rehabilitation. One of the important methods in helping to carry out efficient rehabilitation processes and exercises is the use of games. The aim of this study is to identify the parameters necessary to design a successful rehabilitation game and the outcomes of using these games in upper limb disabilities rehabilitation.

Methods

This scoping review was conducted by searching the Web of Science, PubMed, and Scopus. The eligibility criteria were: any form of game-based upper limb rehabilitation, published in a peer-reviewed journal, published in English, and not include articles that did not focus upper limb disabilities rehabilitation games, review, meta-analysis, or conference papers. Analysis of collected data was done using descriptive statistics (frequency and percentage).

Results

The search strategy retrieved 537 relevant articles. Finally, after removing irrelevant and repetitive articles, 21 articles were included in this study. Among the six categories of diseases or complications of upper limb disabilities, games were mostly designed for stroke patients. Smart wearables, robots and telerehabilitation were three technologies that were used for rehabilitation along with games. Sports and shooters were the most used games for upper limb disability rehabilitation. Among 99 necessary parameters for designing and implementing a successful rehabilitation game in ten categories. "Increasing the patient's motivation to perform rehabilitation exercises", "Game difficulty levels", "Enjoying and the attractiveness of the game for patients", and "Providing positive or negative audiovisual feedback" were the most important parameters. "Improvement in musculoskeletal performance" and "Increasing users' enjoyment/joy of therapeutic exercises and their motivation to perform these exercises" were the most important positive outcomes, and "Mild discomfort such as nausea and dizziness when using games" was the only negative outcome.

Conclusions

The successful design of a game according to the parameters identified in the present study can lead to an increase in the positive outcomes of using games in the rehabilitation of disabilities. The study results indicate that upper limb therapeutic exercise augmented with virtual reality games may be highly effective in enhancing motor rehabilitation outcomes.

Factors that influence the provision of home-based rehabilitation services for people needing rehabilitation: a qualitative evidence synthesis

BACKGROUND

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve.

OBJECTIVES

To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation.

SEARCH METHODS

We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022.  SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions.   DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach.  MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members.  Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation  Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others.  Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members.  In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services.  Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances.

AUTHORS' CONCLUSIONS

This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Understanding the facilitators and barriers of stroke survivors' adherence to recovery-oriented self-practice: a thematic synthesis

PURPOSE

Stroke survivors receive considerable rehabilitation efforts as inpatients, but one-on-one therapy decreases after discharge. The gap between the amount of required therapy and the lack of its availability in this phase of care may be partly overcome by self-practice. However, patient's adherence to prescribed programs is often low. While single studies have examined factors affecting adherence in this specific case, they have not been reviewed and synthesised previously.

METHODS

A thematic synthesis of qualitative studies explored factors affecting stroke survivors' adherence to prescribed, recovery-oriented self-practice. Five databases were systematically searched for references: Medline, Psycinfo, CINAHL, Embase, and ASSIA. Quality assessment was undertaken using the CASP tool.

RESULTS

From 1308 references, 68 potential papers were read in full, and 12 were included in the review. An overarching theme was identified as: "Tailoring and personalization rather than standardization." It was informed by the following three analytical themes: "The meaning of 'self' in self-practice," "Identifying self-practice as a team effort," and "Self-practice that is grounded in one's reality."

CONCLUSION

To have a positive effect on adherence to self-practice, clinicians are advised to spend time learning about each individual's life circumstances, so they can tailor proposed exercise programs to patients' personal situations, preferences, and needs.IMPLICATIONS FOR REHABILITATIONThe topic of patient's adherence to self-practice of prescribed exercise is a common concern, often voiced by frustrated rehabilitation health professionals. Bridging the gap between the patient's needs for post-discharge intensive therapy and the inability of healthcare systems to provide it could be filled partly by self-practice.Adherence to self-practice has become even more essential since the COVID 19 pandemic and the decrease in face-to-face delivery of rehabilitation due to social distancing requirements.Adherence to exercise is a broad topic. Reasons for poor adherence differ between patient populations and the exercises they are prescribed. This study focuses on post-discharge stroke survivors' adherence to recovery targeted exercise that could be described as repetitive and less physically demanding movements and functions.Reviewed studies were qualitative and usually included a relatively small number of participants within a specific context. Using thematic synthesis, we combined these small pieces of the puzzle into a larger picture, to produce recommendations that could be drawn on by clinicians to improve self-practice adherence.

Surface Electromyography-Driven Therapeutic Gaming for Rehabilitation of Upper Extremity Weakness: A Pilot Study

SUMMARY

In patients with severe upper extremity weakness that may result from peripheral nerve injuries, stroke, and spinal cord injuries, standard therapy in the earliest stages of recovery consists primarily of passive rather than active exercises. Adherence to prescribed therapy may be poor, which may contribute to suboptimal functional outcomes. The authors have developed and integrated a custom surface electromyography device with a video game to create an interactive, biofeedback-based therapeutic gaming platform. Sensitivity of the authors' custom surface electromyography device was evaluated with simultaneous needle electromyography recordings. Testing of this therapeutic gaming platform was conducted with a single 30-minute gameplay session in 19 patients with a history of peripheral nerve injury, stroke, spinal cord injury, and direct upper extremity trauma, including 11 patients who had undergone nerve and/or tendon transfers. The device was highly sensitive in detecting low levels of voluntary muscle activation and was used with 10 distinct muscles of the arm, forearm, and hand. Nerve and tendon transfer patients successfully activated the donor nerve/muscle and elicited the desired movement to engage in gameplay. On surveys of acceptability and usability, patients felt the system was enjoyable, motivating, fun, and easy to use, and their hand therapists expressed similar enthusiasm. Surface electromyography-based therapeutic gaming is a promising approach to rehabilitation that warrants further development and investigation to examine its potential efficacy, not only for building muscle strength and endurance but also for facilitating motor relearning after nerve and tendon transfer surgical procedures.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Attitudes and use patterns for mobile technology and upper extremity home exercises in stroke survivors in the United States

Introduction

The use of mobile technology (MT) in home-based occupational therapy is expected to continue growing. This study describes daily use patterns for MT and upper extremity (UE) home exercise programs (HEPs) for community-dwelling stroke survivors in the United States.

Method

Cross-sectional survey. Data were analyzed using descriptive statistics and bivariate comparisons.

Results

N = 61 (30 stroke and 31 controls). Individuals with stroke had similar levels of knowledge, skill, and use of MT compared with non-disabled age-matched adults. Stroke participants used MT more frequently for information searching, social media, and reminders compared to control participants. Stroke participants were motivated to improve UE function (93.3%) and reported a need for additional HEP training (56.7%). Perceived facilitators to improve UE use included talking to peers (73.3%), getting more information (73.3%), and talking to a therapist (63.3%).

Conclusions

MT may have multiple potential benefits when integrated into occupational therapy practice including supporting instrumental ADLs, facilitating social connection, and increasing adherence to UE HEPs. Future work should focus on maximizing adherence and providing performance feedback through the use of social media to promote peer support and consistent remote communication using text messaging, phone calls, or video calls to deliver information and reminders on exercises.

Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines

Ensuring proper dosage of treatment and repetition over time is a major challenge in neurorehabilitation. However, a requirement of physical distancing to date compromises their achievement. While mostly associated to COVID-19, physical distancing is not only required in a pandemic scenario, but also advised for several clinical conditions (e.g. immunocompromised individuals) or forced for specific social contexts (e.g. people living in remote areas worldwide). All these contexts advocate for the implementation of alternative healthcare models. The objective of this perspective is to highlight the benefits of remote administration of rehabilitative treatment, namely telerehabilitation, in counteracting physical distancing barriers in neurorehabilitation. Sustaining boosters of treatment outcome, such as compliance, sustainability, as well as motivation, telerehabilitation may adapt to multiple neurological conditions, with the further advantage of a high potential for individualization to patient's or pathology's specificities. The effectiveness of telerehabilitation can be potentiated by several technologies available to date: virtual reality can recreate realistic environments in which patients may bodily operate, wearable sensors allow to quantitatively monitor the patient's performance, and signal processing may contribute to the prediction of long-term dynamics of patient recovery. Telerehabilitation might spark its advantages far beyond the mere limitation of physical distancing effects, mitigating criticalities of daily neurorehabilitative practice, and thus paving the way to the envision of mixed models of care, where hospital-based procedures are complementarily integrated with telerehabilitative ones.

Upper Limb Rehabilitation Tools in Virtual Reality Based on Haptic and 3D Spatial Recognition Analysis: A Pilot Study

With aging, cerebrovascular diseases can occur more often. Stroke cases involve hemiplegia, which causes difficulties in performing activities of daily living. Existing rehabilitation treatments are based on the subjective evaluation of the therapist as the need for non-contact care arises; it is necessary to develop a system that can self-rehabilitate and offer objective analysis. Therefore, we developed rehabilitation tools that enable self-rehabilitation exercises in a virtual space based on haptics. Thirty adults without neurological damage were trained five times in a virtual environment, and the time, number of collisions, and coordinates were digitized and stored in real time. An analysis of variance (ANOVA) of the time and distance similarity changes revealed that as the number of rounds increased, no changes or increases occurred (p ≥ 0.05), and the collisions and paths were stable as the training progressed (p < 0.05). ANOVA showed a high correlation (0.90) with a decrease in the number of crashes and time required. It was meaningful to users when performing rehabilitation training more than four times and significantly impacted the analysis. This study analyzed the upper limb and cognitive rehabilitation of able-boded people in three-dimensional space in a virtual environment; the performance difficulty could be controlled through variations in rehabilitation models.

Perseverance with technology-facilitated home-based upper limb practice after stroke: a systematic mixed studies review

Background

Technology is being increasingly investigated as an option to allow stroke survivors to exploit their full potential for recovery by facilitating home-based upper limb practice. This review seeks to explore the factors that influence perseverance with technology-facilitated home-based upper limb practice after stroke.

Methods

A systematic mixed studies review with sequential exploratory synthesis was undertaken. Studies investigating adult stroke survivors with upper limb disability undertaking technology-facilitated home-based upper limb practice administered ≥ 3 times/week over a period of ≥ 4 weeks were included. Qualitative outcomes were stroke survivors’ and family members’ perceptions of their experience utilising technology to facilitate home-based upper limb practice. Quantitative outcomes were adherence and dropouts, as surrogate measures of perseverance. The Mixed Methods Appraisal Tool was used to assess quality of included studies.

Results

Forty-two studies were included. Six studies were qualitative and of high quality; 28 studies were quantitative and eight were mixed methods studies, all moderate to low quality. A conceptual framework of perseverance with three stages was formed: (1) getting in the game; (2) sticking with it, and; (3) continuing or moving on. Conditions perceived to influence perseverance, and factors mediating these conditions were identified at each stage. Adherence with prescribed dose ranged from 13 to 140%. Participants were found to be less likely to adhere when prescribed sessions were more frequent (6–7 days/week) or of longer duration (≥ 12 weeks).

Conclusion

From the mixed methods findings, we propose a framework for perseverance with technology-facilitated home-based upper limb practice. The framework offers opportunities for clinicians and researchers to design strategies targeting factors that influence perseverance with practice, in both the clinical prescription of practice and technology design. To confirm the clinical utility of this framework, further research is required to explore perseverance and the factors influencing perseverance.

Registration: PROSPERO CRD42017072799—https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=72799

Wearables in der Schlaganfallmedizin

Unter Wearables versteht man in die Kleidung oder in tragbare Geräte integrierte Sensoren, die eine kontinuierliche Langzeitmessung von physiologischen Parametern, wie Herzfrequenz, Blutdruck, Atmung, Bewegung, Hautwiderstand usw. und/oder Bewegungsmustern ermöglichen. In der Schlaganfallmedizin eröffnen Wearables neue Optionen in der Diagnostik, Prävention und Rehabilitation.

Telerehabilitation in response to constrained physical distance: an opportunity to rethink neurorehabilitative routines

Ensuring proper dosage of treatment and repetition over time is a major challenge in neurorehabilitation. However, a requirement of physical distancing to date compromises their achievement. While mostly associated to COVID-19, physical distancing is not only required in a pandemic scenario, but also advised for several clinical conditions (e.g. immunocompromised individuals) or forced for specific social contexts (e.g. people living in remote areas worldwide). All these contexts advocate for the implementation of alternative healthcare models. The objective of this perspective is to highlight the benefits of remote administration of rehabilitative treatment, namely telerehabilitation, in counteracting physical distancing barriers in neurorehabilitation. Sustaining boosters of treatment outcome, such as compliance, sustainability, as well as motivation, telerehabilitation may adapt to multiple neurological conditions, with the further advantage of a high potential for individualization to patient's or pathology's specificities. The effectiveness of telerehabilitation can be potentiated by several technologies available to date: virtual reality can recreate realistic environments in which patients may bodily operate, wearable sensors allow to quantitatively monitor the patient's performance, and signal processing may contribute to the prediction of long-term dynamics of patient recovery. Telerehabilitation might spark its advantages far beyond the mere limitation of physical distancing effects, mitigating criticalities of daily neurorehabilitative practice, and thus paving the way to the envision of mixed models of care, where hospital-based procedures are complementarily integrated with telerehabilitative ones.

Using the Technology Acceptance Model to Identify Factors That Predict Likelihood to Adopt Tele-Neurorehabilitation

Tele-neurorehabilitation has the potential to reduce accessibility barriers and enhance patient outcomes through a more seamless continuum of care. A growing number of studies have found that tele-neurorehabilitation produces equivalent results to usual care for a variety of outcomes including activities of daily living and health related quality of life. Despite the potential of tele-neurorehabilitation, this model of care has failed to achieve mainstream adoption. Little is known about feasibility and acceptability of tele-neurorehabilitation and most published studies do not use a validated model to guide and evaluate implementation. The technology acceptance model (TAM) was developed 20 years ago and is one of the most widely used theoretical frameworks for predicting an individual's likelihood to adopt and use new technology. The TAM3 further built on the original model by incorporating additional elements from human decision making such as computer anxiety. In this perspective, we utilize the TAM3 to systematically map the findings from existing published studies, in order to explore the determinants of adoption of tele-neurorehabilitation by both stroke survivors and prescribing clinicians. We present evidence suggesting that computer self-efficacy and computer anxiety are significant predictors of an individual's likelihood to use tele-neurorehabilitation. Understanding what factors support or hinder uptake of tele-neurorehabilitation can assist in translatability and sustainable adoption of this technology. If we are to shift tele-neurorehabilitation from the research domain to become a mainstream health sector activity, key stakeholders must address the barriers that have consistently hindered adoption.

"It's All Sort of Cool and Interesting…but What Do I Do With It?" A Qualitative Study of Stroke Survivors' Perceptions of Surface Electromyography

Background: Stroke is one of the most common neurologic injuries worldwide. Over decades, evidence-based neurorehabilitation research and advancements in wireless, wearable sensor design have supported the deployment of technologies to facilitate recovery after stroke. Surface electromyography (sEMG) is one such technology, however, clinical application remains limited. To understand this translational practice gap and improve clinical uptake, it is essential to include stakeholder voices in an analysis of neurorehabilitation practice, the acceptability of current sEMG technologies, and facilitators and barriers to sEMG use in the clinic and the community. The purpose of this study was to foreground the perspectives of stroke survivors to gain a better understanding of their experiences in neurorehabilitation, the technologies they have used during their recovery, and their opinions of lab-designed and commercially-available sEMG systems. Methods: A qualitative, phenomenological study was completed. In-depth, semi-structured interviews were conducted with eight stroke survivors (age range 49-78 years, 6 months to 12 years post-stroke) and two caregivers from a large metropolitan region. A demonstration of four sEMG systems was provided to gather perceptions of sensor design, features and function, and user interface. Interviews were audio-recorded, transcribed verbatim, and coded for analysis using constant comparison until data saturation was reached. Results: Three themes emerged from the data: (1) "Surface EMG has potential….but…" highlights the recognition of sEMG as a valuable tool but reveals a lack of understanding and need for clear meaning from the data; (2) "Tracking incremental progress over days or years is important" highlights the persistence of hope and potential benefit of sEMG in detecting small changes that may inform neurorehabilitation practice and policy; and (3) "Neurorehabilitation technology is cumbersome" highlights the tension between optimizing therapy time and trying new technologies, managing cost, logistics and set-up, and desired technology features. Conclusion: Further translation of sEMG technology for neurorehabilitation holds promise for stroke survivors, but sEMG system design and user interface needs refinement. The process of using sEMG technology and products must be simple and provide meaningful insight to recovery. Including stroke survivors directly in translational efforts is essential to improve uptake in clinical environments.

Surface EMG in Clinical Assessment and Neurorehabilitation: Barriers Limiting Its Use

This article addresses the potential clinical value of techniques based on surface electromyography (sEMG) in rehabilitation medicine with specific focus on neurorehabilitation. Applications in exercise and sport pathophysiology, in movement analysis, in ergonomics and occupational medicine, and in a number of related fields are also considered. The contrast between the extensive scientific literature in these fields and the limited clinical applications is discussed. The "barriers" between research findings and their application are very broad, and are longstanding, cultural, educational, and technical. Cultural barriers relate to the general acceptance and use of the concept of objective measurement in a clinical setting and its role in promoting Evidence Based Medicine. Wide differences between countries exist in appropriate training in the use of such quantitative measurements in general, and in electrical measurements in particular. These differences are manifest in training programs, in degrees granted, and in academic/research career opportunities. Educational barriers are related to the background in mathematics and physics for rehabilitation clinicians, leading to insufficient basic concepts of signal interpretation, as well as to the lack of a common language with rehabilitation engineers. Technical barriers are being overcome progressively, but progress is still impacted by the lack of user-friendly equipment, insufficient market demand, gadget-like devices, relatively high equipment price and a pervasive lack of interest by manufacturers. Despite the recommendations provided by the 20-year old EU project on "Surface EMG for Non-Invasive Assessment of Muscles (SENIAM)," real international standards are still missing and there is minimal international pressure for developing and applying such standards. The need for change in training and teaching is increasingly felt in the academic world, but is much less perceived in the health delivery system and clinical environments. The rapid technological progress in the fields of sensor and measurement technology (including sEMG), assistive devices, and robotic rehabilitation, has not been driven by clinical demands. Our assertion is that the most important and urgent interventions concern enhanced education, more effective technology transfer, and increased academic opportunities for physiotherapists, occupational therapists, and kinesiologists.

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.

Home program practices for supporting and measuring adherence in post-stroke rehabilitation: a scoping review

BACKGROUND

After stroke, individuals face a variety of impairments that impact function. Increasingly, rehabilitation for these impairments has moved into the community and home settings through the use of home programs. However, adherence to these programs is often low, limiting effectiveness.

OBJECTIVE

This scoping review investigated home program implementation and measurement of adherence with persons post-stroke to identify commonly reported practices and determine areas for further research.

METHODS

The electronic databases of PubMed, CINAHL, Scopus, Cochrane Database of Systematic Reviews, and PEDro were searched. Studies focused on post-stroke rehabilitation with an independent home program were selected. Qualitative studies, commentaries, and single-case studies were excluded. Title and abstract screenings were completed by two reviewers with a third for tie-breaking. The full-text review was completed by two reviewers using consensus to resolve any differences. Of the 1,197 articles initially found only 6% (n = 70) met criteria for data extraction. Elements for data extraction included: type of study, area of intervention, description of home program, presence of strategies to support adherence, methods to measure adherence and reported adherence.

RESULTS

Most commonly reported strategies to support home practice were the use of technology, personalization, and written directions. Only 20 studies reported achieving adherence at or greater than 75% and 18 studies did not report adherence outcomes.

CONCLUSIONS

Future investigations that directly compare and identify the most effective strategies to support adherence to home programs for this population are warranted. The implementation of guidelines for reporting adherence to home programs is recommended.

Wearable technology in stroke rehabilitation: towards improved diagnosis and treatment of upper-limb motor impairment

Stroke is one of the main causes of long-term disability worldwide, placing a large burden on individuals and society. Rehabilitation after stroke consists of an iterative process involving assessments and specialized training, aspects often constrained by limited resources of healthcare centers. Wearable technology has the potential to objectively assess and monitor patients inside and outside clinical environments, enabling a more detailed evaluation of the impairment and allowing the individualization of rehabilitation therapies. The present review aims to provide an overview of wearable sensors used in stroke rehabilitation research, with a particular focus on the upper extremity. We summarize results obtained by current research using a variety of wearable sensors and use them to critically discuss challenges and opportunities in the ongoing effort towards reliable and accessible tools for stroke rehabilitation. Finally, suggestions concerning data acquisition and processing to guide future studies performed by clinicians and engineers alike are provided.

Viability of using a computer tablet to monitor an upper limb home exercise program in stroke

Aims: To evaluate the feasibility of using a tablet computer to monitor the amount of upper limb practice completed by stroke patients prescribed with a home program and to explore factors that influence adherence. Method: Ten consecutive participants randomized to the intervention arm of a randomized controlled trial investigating therapy after spasticity management for stroke patients (ACTRN 12615000616572) were recruited for this sub-study. Participants were asked to perform and record a prescribed 60-min upper limb program, based on the Graded Arm Supplementary Program, on a tablet computer daily. Four randomly selected recorded sessions for each participant were analyzed by the physiotherapist to assess adherence to the amount of exercise and content. Results: Mean score for the System Usability Scale was 85.5 (range 47.5-100) indicating that participants were accepting of the technology. Participants performed exercises on average for 50.32 min (range 26.42-68.37). Self-reported practice time was 59.44 min (range 48-67.5). Conclusion: Monitoring of patient practice using a tablet computer is feasible and may prove more reliable than self-report. There is variability in the amount of upper limb exercise stroke patients do at home.

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.

Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke (RHOMBUS): protocol of an intervention feasibility trial

INTRODUCTION

Effective interventions to promote upper-limb recovery poststroke are characterised by intensive and repetitive movements. However, the repetitive nature of practice may adversely impact on adherence. Therefore, the development of rehabilitation devices that can be used safely and easily at home, and are motivating, enjoyable and affordable is essential to the health and well-being of stroke survivors.The Neurofenix platform is a non-immersive virtual reality device for poststroke upper-limb rehabilitation. The platform uses a hand controller (a NeuroBall) or arm bands (NeuroBands) that facilitate upper-limb exercise via games displayed on a tablet. The Rehabilitation via HOMe Based gaming exercise for the Upper-limb post Stroke trial aims to determine the safety, feasibility and acceptability of the Neurofenix platform for home-based rehabilitation of the upper-limb poststroke.

METHODS AND ANALYSIS

Thirty people poststroke will be provided with a Neurofenix platform, consisting of a NeuroBall or NeuroBands (dependent on impairment level), seven specially designed games, a tablet and handbook to independently exercise their upper limb for 7 weeks. Training commences with a home visit from a research therapist to teach the participant how to safely use the device. Outcomes assessed at baseline and 8 weeks and 12 weeks are gross level of disability, pain, objectively measured arm function and impairment, self-reported arm function, passive range of movement, spasticity, fatigue, participation, quality of life (QOL) and health service use. A parallel process evaluation will assess feasibility, acceptability and safety of the intervention through assessment of fidelity to the intervention measured objectively through the Neurofenix platform, a postintervention questionnaire and semistructured interviews exploring participants' experiences of the intervention. The feasibility of conducting an economic evaluation will be determined by collecting data on QOL and resource use.

ETHICS AND DISSEMINATION

Ethics approval granted from Brunel University London (10249-MHR-Mar/2018-12322-2). Trial results will be submitted for publication in journals, presented at national and international conferences and distributed to people with stroke.

TRIAL REGISTRATION NUMBER

ISRCTN60291412; Pre-results.

Mobile Game Induces Active Engagement on Neuromuscular Electrical Stimulation Training in Patients with Stroke

This study aimed to investigate the effectiveness of the mobile game-based neuromuscular electrical stimulation (MG-NMES) with assessing usability issues, such as attention and curiosity, and intrinsically interesting issues, which is necessary for successful poststroke rehabilitation. With the conventional NMES (C-NMES) system, the subjects underwent active repetitive cyclic NMES training. For assessment of usability issues, 20 hemiplegic stroke subjects were randomly divided into two groups. The subjects in the MG-NMES group (n = 9) and C-NMES group (n = 11) underwent 20 minutes of training each day for 5 days. We assessed the subjects' attention, curiosity, and intrinsically interesting issues; and using questionnaires they answered questions regarding their expectations of the training outcome after each training session. We found that the subjects in the MG-NMES group maintained their attention and interest for the 5 days, and their curiosity and expectation of a positive training outcome gradually increased as the training proceeded. In contrast, the C-NMES group reported no change in their attention or curiosity, but it was lower than the subjects in the MG-NMES group. In addition, their interest gradually decreased, which may have reduced their expectations of a positive outcome as the sessions progressed. There were no side effects during the training sessions in either group. The MG-NMES training paradigm developed is a new, readily available, and highly motivating MG-NMES training system. Based on the usability test, the reported advantages of the system were improved attention and flow experience during NMES training.

A video-game group intervention: Experiences and perceptions of adults with chronic stroke and their therapists: Intervention de groupe à l'aide de jeux vidéo : Expériences et perceptions d'adultes en phase chronique d'un accident vasculaire cérébral et de leurs ergothérapeutes

BACKGROUND

Ongoing physical activity is important for maintaining the functional level of individuals with chronic stroke. Video games in a group setting might be a cost-effective way for providing mobility and preventing physical inactivity.

PURPOSE

This study explores the experiences and perceptions of individuals with chronic stroke who participated in a novel community-based video-game group intervention and their therapists.

METHOD

A qualitative study, nested in a randomized controlled trial, was conducted using semistructured interviews with eight individuals with chronic stroke (four men and four women) ages 29 to 69 and a focus group of their three occupational therapists, following a video-game intervention. Data were analyzed using content analysis.

FINDINGS

Three main categories were identified by the study participants: (a) using video games, (b) the group/team experience, and (c) intervention outcomes/evolving understandings following the intervention.

IMPLICATIONS

Playing video games was perceived not as treatment but as a motivating tool to facilitate whole-body movement. Therefore, this intervention might be suitable to be used in the community for ongoing intervention.

Self-training to improve UE function at the chronic stage post-stroke: a pilot randomized controlled trial

BACKGROUND AND PURPOSE

On-going practice and use of the weaker upper extremity (UE) are important for maintaining and improving function in individuals with chronic stroke. The effectiveness of two self-training programs for UE function and daily-use was compared.

METHODS

In this pilot, single-blinded clinical trial, individuals with chronic stroke were randomized to video-games or traditional self-training (1-hour/day, 6-times/week, 5 weeks). Assessments were performed pre-intervention (an average of two assessments), post-intervention, and at 4-week follow-up. The primary outcome was the functional ability of the upper extremity [The Action Research Arm Test (ARAT)]. Secondary measures were the daily use of the upper extremity [Motor Activity Log (MAL)] and manual dexterity (Box and Block Test). Repeated measures ANOVA was used to test the effectiveness and estimate effect sizes.

RESULTS

Twenty-four of the 142 participants screened by phone were randomized to video-games [N = 13, mean (SD) age - 59.1 (10.5)] or traditional [N = 11, mean (SD) age - 64.9 (6.9)] self-training. Significant between-group differences were not detected. ARAT significantly improved by 13.9% and 9.6% following the video-games and traditional self-training programs (respectively), with a large effect size. MAL (quantity) also improved significantly between pre- intervention to follow-up with medium-large effect size.

CONCLUSIONS

UE functional improvement can be achieved by self-training at the chronic stage and, therefore, should be encouraged by clinicians. Implications for rehabilitation Video-games or traditional self-training programs can be used to practice repetitive UE movements without the supervision of a clinician Self-training of the UE is beneficial at the chronic stage post-stroke and, therefore, should be encouraged The type of self-training (video-games or traditional) should be suited to the client's abilities and preferences. The compliance of self-training using video-games during the follow-up period was higher than the traditional self-training. This is important since self-training programs for chronic stroke need to be long-term and sustainable.

The Relationship Between Engagement and Neurophysiological Measures of Attention in Motion-Controlled Video Games: A Randomized Controlled Trial

Background

Video games and virtual environments continue to be the subject of research in health sciences for their capacity to augment practice through user engagement. Creating game mechanics that increase user engagement may have indirect benefits on learning (ie, engaged learners are likely to practice more) and may also have direct benefits on learning (ie, for a fixed amount of practice, engaged learners show superior retention of information or skills).

Objective

To manipulate engagement through the aesthetic features of a motion-controlled video game and measure engagement’s influence on learning.

Methods

A group of 40 right-handed participants played the game under two different conditions (game condition or sterile condition). The mechanics of the game and the amount of practice were constant. During practice, event-related potentials (ERPs) to task-irrelevant probe tones were recorded during practice as an index of participants’ attentional reserve. Participants returned for retention and transfer testing one week later.

Results

Although both groups improved in the task, there was no difference in the amount of learning between the game and sterile groups, countering previous research. A new finding was a statistically significant relationship between self-reported engagement and the amplitude of the early-P3a (eP3a) component of the ERP waveform, such that participants who reported higher levels of engagement showed a smaller eP3a (beta=−.08, P=.02).

Conclusions

This finding provides physiological data showing that engagement elicits increased information processing (reducing attentional reserve), which yields new insight into engagement and its underlying neurophysiological properties. Future studies may objectively index engagement by quantifying ERPs (specifically the eP3a) to task-irrelevant probes.

Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation

Background

The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming.

Methods

We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire.

Results

In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p < .001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p = .074), significantly shorter travel distance (p < .001), higher movement efficiency (p < .001) and higher performance scores (p < .001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance.

Conclusions

Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation.