Design, development and deployment of a hand/wrist exoskeleton for home-based rehabilitation after stroke - SCRIPT project

Active, Actuated, and Assistive: a Scoping Review of Exoskeletons for the Hands and Wrists

BACKGROUND

Assistive technology is often incorporated into rehabilitation and support for those impacted by upper limb impairments. When powered, these devices provide additional force to the joints of users with muscle weakness. Actuated devices allow dynamic movement compared to splints, therefore improving the ability to complete activities of daily living. However, these devices are not often prescribed and are underrepresented in research and clinical settings.

OBJECTIVE

This review examined the existing literature on devices developed to support hand and wrist functionality in daily activities. Focusing on active, powered, and actuated devices, to gain a clearer understanding of the current limitations in their design and prescription.

METHODOLOGY

The scoping review was conducted using the PRISMA-ScR guidelines. A systematic search was done on MEDLINE, EMBASE, Scopus, Web of Science, and NHS the Knowledge Network from inception to May 2023. Articles were included if the device was portable; supported the hands and wrist actively using an actuator; and could be used for assistive living during or post-rehabilitation period.

FINDINGS

A total of 135 studies were included in the analysis of which 34 were clinical trials. The design and control methods of 121 devices were analyzed. Electrical stimulation and direct mechanical transmission were popular actuation methods. Electromyography (EMG) and joint movement detection were highly used control methods to translate user intentions to device actuation. A total of 226 validation methods were reported, of which 44% were clinically validated. Studies were often not conducted in operational environments with 69% at technology readiness levels ≤ 6, indicating that further development and testing is required.

CONCLUSION

The existing literature on hand and wrist exoskeletons presents large variations in validation methods and technical requirements for user-specific characteristics. This suggests a need for well-defined testing protocols and refined reporting of device designs. This would improve the significance of clinical outcomes and new assistive technology.

Understanding the Sociocultural Challenges and Opportunities for Affordable Wearables to Support Poststroke Upper-Limb Rehabilitation: Qualitative Study

Background

People who survive a stroke in many cases require upper-limb rehabilitation (ULR), which plays a vital role in stroke recovery practices. However, rehabilitation services in the Global South are often not affordable or easily accessible. For example, in Bangladesh, the access to and use of rehabilitation services is limited and influenced by cultural factors and patients' everyday lives. In addition, while wearable devices have been used to enhance ULR exercises to support self-directed home-based rehabilitation, this has primarily been applied in developed regions and is not common in many Global South countries due to potential costs and limited access to technology.

Objective

Our goal was to better understand physiotherapists', patients', and caregivers' experiences of rehabilitation in Bangladesh, existing rehabilitation practices, and how they differ from the rehabilitation approach in the United Kingdom. Understanding these differences and experiences would help to identify opportunities and requirements for developing affordable wearable devices that could support ULR in home settings.

Methods

We conducted an exploratory study with 14 participants representing key stakeholder groups. We interviewed physiotherapists and patients in Bangladesh to understand their approaches, rehabilitation experiences and challenges, and technology use in this context. We also interviewed UK physiotherapists to explore the similarities and differences between the 2 countries and identify specific contextual and design requirements for low-cost wearables for ULR. Overall, we remotely interviewed 8 physiotherapists (4 in the United Kingdom, 4 in Bangladesh), 3 ULR patients in Bangladesh, and 3 caregivers in Bangladesh. Participants were recruited through formal communications and personal contacts. Each interview was conducted via videoconference, except for 2 interviews, and audio was recorded with consent. A total of 10 hours of discussions were transcribed. The results were analyzed using thematic analysis.

Results

We identified several sociocultural factors that affect ULR and should be taken into account when developing technologies for the home: the important role of family, who may influence the treatment based on social and cultural perceptions; the impact of gender norms and their influence on attitudes toward rehabilitation and physiotherapists; and differences in approach to rehabilitation between the United Kingdom and Bangladesh, with Bangladeshi physiotherapists focusing on individual movements that are necessary to build strength in the affected parts and their British counterparts favoring a more holistic approach. We propose practical considerations and design recommendations for developing ULR devices for low-resource settings.

Conclusions

Our work shows that while it is possible to build a low-cost wearable device, the difficulty lies in addressing sociotechnical challenges. When developing new health technologies, it is imperative to not only understand how well they could fit into patients', caregivers', and physiotherapists' everyday lives, but also how they may influence any potential tensions concerning culture, religion, and the characteristics of the local health care system.

Multidisciplinary collaboration on exoskeleton development adopting user-centered design: a systematic integrative review

Purpose: The world population is ageing, along with an increasing possibility of functional limitations that affect independent living. Assistive technologies such as exoskeletons for rehabilitative purposes and daily activities assistance maintaining the independence of people with disabilities, especially older adults who wish to ageing-in-place. The purpose of this systematic integrative review was threefold: to explore the development team compositions and involvement, to understand the recruitment and engagement of stakeholders, and to synthesise reported or anticipated consequences of multidisciplinary collaboration.Methods: Databases searched included PubMed, CINAHL Plus, PsycINFO, Web of Science, Scopus, and IEEE Xplore. A total of 34 studies that reported the development of exoskeleton adopting user-centered design (UCD) method in healthcare or community settings that were published in English from 2000 to July 2022 were included.Results: Three major trends emerged from the analysis of included studies. First, there is a need to redefine multidisciplinary collaboration, from within-discipline collaboration to cross-discipline collaboration. Second, the level of engagement of stakeholders during the exoskeleton development remained low. Third, there was no standardised measurement to quantify knowledge production currently.Conclusion: As suggested by the synthesised results in this review, exoskeleton development has been increasing to improve the functioning of people with disabilities. Exoskeleton development often required expertise from different disciplines and the involvement of stakeholders to increase acceptance, thus we propose the Multidisciplinary Collaboration Appraisal Tool to assess multidisciplinary collaboration using the UCD approach. Future research is required to understand the effectiveness of multidisciplinary collaboration on exoskeleton development using the UCD approach.IMPLICATIONS FOR REHABILITATIONGlobal trend of population ageing causes a higher risk of disability in older adults who require rehabilitation and assistance in daily living.Assistive technologies such as exoskeletons have the potential to contribute to rehabilitation training and daily activity assistance demand closer multidisciplinary collaboration.A Multidisciplinary Collaboration Appraisal Tool using user-centered design approach (MCAT) is proposed to understand the effectiveness as well as limitations and barriers associated with multidisciplinary collaboration in developing exoskeletons.

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.

Preliminary Results from a Six-Week Home-Based Evaluation of a Rehabilitation Device for Hand and Wrist Therapy After Stroke

While many robot-aided solutions have been proposed for the rehabilitation of the distal segment of the upper limb, very few take into account the synergy between the wrist and fingers to allow them to train simultaneously in a home environment. WiGlove is a passive robotic orthosis designed to address this need. This wearable, wireless device enables stroke survivors to perform flexion/extension exercises of both the wrist and fingers while performing ADL or playing therapeutic computer games. As a part of its user-centred design process, this paper presents a case study of a 6-week feasibility evaluation of the WiGlove conducted at a stroke survivor's home without assistance from the therapists. The participant trained with the device for an average of 48 minutes a day and showed a noticeable reduction in the spasticity of the fingers and improved performance in the box and block test. He expressed satisfaction with its usability and suitability for the home environment. These results show overwhelmingly positive outcomes in terms of its acceptance, usability and effectiveness in offering home-based rehabilitation of the wrist and fingers.

Home-based upper limb stroke rehabilitation mechatronics: challenges and opportunities

Interest in home-based stroke rehabilitation mechatronics, which includes both robots and sensor mechanisms, has increased over the past 12 years. The COVID-19 pandemic has exacerbated the existing lack of access to rehabilitation for stroke survivors post-discharge. Home-based stroke rehabilitation devices could improve access to rehabilitation for stroke survivors, but the home environment presents unique challenges compared to clinics. The present study undertakes a scoping review of designs for at-home upper limb stroke rehabilitation mechatronic devices to identify important design principles and areas for improvement. Online databases were used to identify papers published 2010-2021 describing novel rehabilitation device designs, from which 59 publications were selected describing 38 unique designs. The devices were categorized and listed according to their target anatomy, possible therapy tasks, structure, and features. Twenty-two devices targeted proximal (shoulder and elbow) anatomy, 13 targeted distal (wrist and hand) anatomy, and three targeted the whole arm and hand. Devices with a greater number of actuators in the design were more expensive, with a small number of devices using a mix of actuated and unactuated degrees of freedom to target more complex anatomy while reducing the cost. Twenty-six of the device designs did not specify their target users' function or impairment, nor did they specify a target therapy activity, task, or exercise. Twenty-three of the devices were capable of reaching tasks, 6 of which included grasping capabilities. Compliant structures were the most common approach of including safety features in the design. Only three devices were designed to detect compensation, or undesirable posture, during therapy activities. Six of the 38 device designs mention consulting stakeholders during the design process, only two of which consulted patients specifically. Without stakeholder involvement, these designs risk being disconnected from user needs and rehabilitation best practices. Devices that combine actuated and unactuated degrees of freedom allow a greater variety and complexity of tasks while not significantly increasing their cost. Future home-based upper limb stroke rehabilitation mechatronic designs should provide information on patient posture during task execution, design with specific patient capabilities and needs in mind, and clearly link the features of the design to users' needs.

Internet of Things (IoT) Enables Robot-Assisted Therapy as a Home Program for Training Upper Limb Functions in Chronic Stroke: A Randomized Control Crossover Study

OBJECTIVE

To compare the effects of using an Internet of things (IoT)-assisted tenodesis-induced-grip exoskeleton robot (TIGER) and task-specific motor training (TSMT) as home programs for the upper-limb (UL) functions of patients with chronic stroke to overturn conventional treatment modes for stroke rehabilitation.

DESIGN

A randomized 2-period crossover study.

SETTING

A university hospital.

PARTICIPANTS

Eighteen chronic stroke patients were recruited and randomized to receive either the IoT-assisted TIGER first or TSMT first at the beginning of the experiment (N=18).

INTERVENTION

In addition to the standard hospital-based therapy, participants were allocated to receive a 30-minute home-based, self-administered program of either IoT-assisted TIGER first or TSMT first twice daily for 4 weeks, with the order of both treatments reversed after a 12-week washout period. The exercise mode of the TIGER training included continuous passive motion and the functional mode of gripping pegs. The TSMT involved various movement components of the wrist and hand.

MAIN OUTCOME MEASURES

The outcome measures included the box and block test (BBT), the Fugl-Meyer assessment for upper extremity (FMA-UE), the motor activity log, the Semmes-Weinstein Monofilament test, the range of motion (ROM) of the wrist joint, and the modified Ashworth scale.

RESULTS

Significant treatment-by-time interaction effects emerged in the results for the BBT (F(1.31)=5.212 and P=.022), the FMA-UE (F(1.31)=6.807 and P=.042), and the ROM of the wrist extension (F(1.31)=8.618 and P=.009). The participants who trained at home with the IoT-assisted TIGER showed more improvement of their UL functions.

CONCLUSIONS

The IoT-assisted TIGER training has the potential for restoring the UL functions of stroke patients.

Optimized Home Rehabilitation Technology Reduces Upper Extremity Impairment Compared to a Conventional Home Exercise Program: A Randomized, Controlled, Single-Blind Trial in Subacute Stroke

BACKGROUND

Upper extremity (UE) stroke rehabilitation requires patients to perform exercises at home, yet patients show limited benefit from paper-based home exercise programs.

OBJECTIVE

To compare the effectiveness of 2 home exercise programs for reducing UE impairment: a paper-based approach and a sensorized exercise system that incorporates recommended design features for home rehabilitation technology.

METHODS

In this single-blind, randomized controlled trial, 27 participants in the subacute phase of stroke were assigned to the sensorized exercise (n = 14) or conventional therapy group (n = 13), though 2 participants in the conventional therapy group were lost to follow-up. Participants were instructed to perform self-guided movement training at home for at least 3 hours/week for 3 consecutive weeks. The sensorized exercise group used FitMi, a computer game with 2 puck-like sensors that encourages movement intensity and auto-progresses users through 40 exercises. The conventional group used a paper book of exercises. The primary outcome measure was the change in Upper Extremity Fugl-Meyer (UEFM) score from baseline to follow-up. Secondary measures included the Modified Ashworth Scale for spasticity (MAS) and the Visual Analog Pain (VAP) scale.

RESULTS

Participants who used FitMi improved by an average of 8.0 ± 4.6 points on the UEFM scale compared to 3.0 ± 6.1 points for the conventional participants, a significant difference (t-test, P = .029). FitMi participants exhibited no significant changes in UE MAS or VAP scores.

CONCLUSIONS

A sensor-based exercise system incorporating a suite of recommended design features significantly and safely reduced UE impairment compared to a paper-based, home exercise program.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03503617.

Analysis of Dynamic Behavior of ParReEx Robot Used in Upper Limb Rehabilitation

This paper presents a dynamic analysis of the ParReEx multibody mechanism, which has been designed for human wrist joint rehabilitation. The starting point of the research is a virtual prototype of the ParReEx multibody mechanism. This model is used to simulate the dynamics of the multibody mechanism using ADAMS in three simulation scenarios: (a) rigid kinematic elements without friction in joints, (b) rigid kinematic elements with friction in joints, and (c) kinematic elements as deformable solids with friction in joints. In all three cases, the robot is used by a virtual patient in the form of a mannequin. Results such as the connecting forces in the kinematic joints and the torques necessary to operate the ParReEx robot modules are obtained by dynamic simulation in MSC.ADAMS. The torques obtained by numerical simulation are compared with those obtained experimentally. Finite element structural optimization (FEA) of the flexion/extension multibody mechanism module is performed. The results demonstrate the operational safety of the ParReEx multibody mechanism, which is structurally capable of supporting the external loads to which it is subjected.

Design of a compliant, stabilizing wrist mechanism for a pediatric hand exoskeleton

Children affected by hand impairment due to cerebral palsy or stroke experience serious difficulties when performing activities of daily life (ADL), which reduces their quality of life and development. Wearable robots such as hand exoskeletons have been proposed to support people with hand impairment in therapy as well as daily tasks. While numerous actuated wearable robots have been developed, few designs support both fingers and wrist function, despite being mutually relevant for reach-to-grasp tasks. A recent feasibility study investigating the use of PEXO, a lightweight and fully wearable pediatric hand exoskeleton, showed that a wrist fixed in a slightly extended position may limit the user's ability to reach and grasp during ADL and restrict the user group. These insights and further interactions with clinicians inspired a novel design of PEXO that features an additional degree of freedom in the wrist. In this paper, we present a compliant wrist mechanism extending the existing leaf spring finger mechanism of the device. The novel design provides both wrist motion capability of 60° in flexion and extension and wrist stabilization at the same time while actively supporting finger motion. Preliminary results suggest that the adjustability in the wrist enables a larger variety of grasping gestures. The implemented wrist support has the potential to allow for a more versatile use of PEXO and increase the potential target user group.

A systematic review on the usability of robotic and virtual reality devices in neuromotor rehabilitation: patients' and healthcare professionals' perspective

BACKGROUND

The application of virtual reality (VR) and robotic devices in neuromotor rehabilitation has provided promising evidence in terms of efficacy, so far. Usability evaluations of these technologies have been conducted extensively, but no overviews on this topic have been reported yet.

METHODS

A systematic review of the studies on patients' and healthcare professionals' perspective through searching of PubMed, Medline, Scopus, Web of Science, CINAHL, and PsychINFO (2000 to 2021) was conducted. Descriptive data regarding the study design, participants, technological devices, interventions, and quantitative and qualitative usability evaluations were extracted and meta-synthetized.

RESULTS

Sixty-eight studies were included. VR devices were perceived as having good usability and as a tool promoting patients' engagement and motivation during the treatment, as well as providing strong potential for customized rehabilitation sessions. By contrast, they suffered from the effect of learnability and were judged as potentially requiring more mental effort. Robotics implementation received positive feedback along with high satisfaction and perceived safety throughout the treatment. Robot-assisted rehabilitation was considered useful as it supported increased treatment intensity and contributed to improved patients' physical independence and psychosocial well-being. Technical and design-related issues may limit the applicability making the treatment difficult and physically straining. Moreover, cognitive and communication deficits were remarked as potential barriers.

CONCLUSIONS

Overall, VR and robotic devices have been perceived usable so far, reflecting good acceptance in neuromotor rehabilitation programs. The limitations raised by the participants should be considered to further improve devices applicability and maximise technological rehabilitation effectiveness.

TRIAL REGISTRATION

PROSPERO registration ref. CRD42021224141 .

EEG Spectral Feature Modulations Associated With Fatigue in Robot-Mediated Upper Limb Gross and Fine Motor Interactions

This paper investigates the EEG spectral feature modulations associated with fatigue induced by robot-mediated upper limb gross and fine motor interactions. Twenty healthy participants were randomly assigned to perform a gross motor interaction with HapticMASTER or a fine motor interaction with SCRIPT passive orthosis for 20 min or until volitional fatigue. Relative and ratio band power measures were estimated from the EEG data recorded before and after the robot-mediated interactions. Paired-samples t-tests found a significant increase in the relative alpha band power and a significant decrease in the relative delta band power due to the fatigue induced by the robot-mediated gross and fine motor interactions. The gross motor task also significantly increased the (θ + α)/β and α/β ratio band power measures, whereas the fine motor task increased the relative theta band power. Furthermore, the robot-mediated gross movements mostly changed the EEG activity around the central and parietal brain regions, whereas the fine movements mostly changed the EEG activity around the frontopolar and central brain regions. The subjective ratings suggest that the gross motor task may have induced physical fatigue, whereas the fine motor task may have induced mental fatigue. Therefore, findings affirm that changes to localised brain activity patterns indicate fatigue developed from the robot-mediated interactions. It can also be concluded that the regional differences in the prominent EEG spectral features are most likely due to the differences in the nature of the task (fine/gross motor and distal/proximal upper limb) that may have differently altered an individual's physical and mental fatigue level. The findings could potentially be used in future to detect and moderate fatigue during robot-mediated post-stroke therapies.

Development and control of a home-based training device for hand rehabilitation with a spring and cable driven mechanism

Rehabilitation at home is rapidly increasing. Although successful results are achieved with treatment methods applied in rehabilitation clinics, there are also some disadvantages in this process, such as dependence on an expert and high costs. Developments in mechatronic technologies have accelerated the development of assistive devices which are designed for use at home. One of the rehabilitation applications is on a hemiplegic hand. In previous studies, some useful devices have been developed for hand rehabilitation. In this study, we suggest a new, low-cost and wearable robotic glove for hand rehabilitation. The specific component of this device is the spring and cable driven system proposed for transmission of motion and force. The device was tested on both unimpaired participants and patients with the hemiplegic hand, and it was proven to be beneficial for hand rehabilitation. As a result of trials with unimpaired participants, the muscle activation of the extensor digitorum and the flexor carpi radialis were increased by 184.1 and 197.8% respectively. The weight of the device was less than 400 g, thanks to 3D printed parts.

Design of a variable stiffness index finger exoskeleton

This paper presents the design and experimentation of a variable stiffness index finger exoskeleton consisting of four-bar mechanisms actuated by a linear actuator. The lengths of the four-bar mechanism were optimized so that it can follow a recorded index fingertip trajectory. The mechanism has a fixed compliance at the coupler of the four-bar link and a variable compliance at the linear actuator that moves the four-bar. The skeletal shape of the coupler of the finger link has been optimized using FEM. The exoskeleton can apply a constant fingertip force irrespective of the position of the fingers.

Assessment Methods of Usability and Cognitive Workload of Rehabilitative Exoskeletons: A Systematic Review

Robotic exoskeleton technologies are applied in the medical field to help patients with impaired mobility to recover their motor functions. Relevant literature shows that usability and cognitive workload may influence the patients’ likelihood to benefit from the use of rehabilitative exoskeletons. Following the PRISMA method, the present study aimed to systematically review the assessment methods of usability and cognitive workload in the use of exoskeletal devices for motor rehabilitation. The literature search was conducted in the Scopus and Web of Science bibliographical databases, using 16 keywords that were combined into one search query. A final sample of 23 articles was included in the review, from which 18 distinct assessment methods were identified. Of them, 15 aimed to assess usability, whereas 3 aimed to assess cognitive workload in the use of rehabilitative exoskeletons. Some of the identified methods (e.g., SUS, QUEST, SWAT, and NASA-TLX) showed good psychometric properties and were therefore proven to be appropriate to assess usability and cognitive workload while performing exoskeleton-based rehabilitation. The current study may contribute to the development of guidelines and analytical tools for exoskeletons’ usability and exoskeleton-related patients’ cognitive workload in the domain of medical rehabilitation.

Robotic Home-Based Rehabilitation Systems Design: From a Literature Review to a Conceptual Framework for Community-Based Remote Therapy During COVID-19 Pandemic

During the COVID-19 pandemic, the higher susceptibility of post-stroke patients to infection calls for extra safety precautions. Despite the imposed restrictions, early neurorehabilitation cannot be postponed due to its paramount importance for improving motor and functional recovery chances. Utilizing accessible state-of-the-art technologies, home-based rehabilitation devices are proposed as a sustainable solution in the current crisis. In this paper, a comprehensive review on developed home-based rehabilitation technologies of the last 10 years (2011-2020), categorizing them into upper and lower limb devices and considering both commercialized and state-of-the-art realms. Mechatronic, control, and software aspects of the system are discussed to provide a classified roadmap for home-based systems development. Subsequently, a conceptual framework on the development of smart and intelligent community-based home rehabilitation systems based on novel mechatronic technologies is proposed. In this framework, each rehabilitation device acts as an agent in the network, using the internet of things (IoT) technologies, which facilitates learning from the recorded data of the other agents, as well as the tele-supervision of the treatment by an expert. The presented design paradigm based on the above-mentioned leading technologies could lead to the development of promising home rehabilitation systems, which encourage stroke survivors to engage in under-supervised or unsupervised therapeutic activities.

Integration of a Passive Exoskeleton and a Robotic Supernumerary Finger for Grasping Compensation in Chronic Stroke Patients: The SoftPro Wearable System

Upper-limb impairments are all-pervasive in Activities of Daily Living (ADLs). As a consequence, people affected by a loss of arm function must endure severe limitations. To compensate for the lack of a functional arm and hand, we developed a wearable system that combines different assistive technologies including sensing, haptics, orthotics and robotics. The result is a device that helps lifting the forearm by means of a passive exoskeleton and improves the grasping ability of the impaired hand by employing a wearable robotic supernumerary finger. A pilot study involving 3 patients, which was conducted to test the capability of the device to assist in performing ADLs, confirmed its usefulness and serves as a first step in the investigation of novel paradigms for robotic assistance.

HoMEcare aRm rehabiLItatioN (MERLIN): telerehabilitation using an unactuated device based on serious games improves the upper limb function in chronic stroke

BACKGROUND

HoMEcare aRm rehabiLItatioN (MERLIN) is an unactuated version of the robotic device ArmAssist combined with a telecare platform. Stroke patients are able to train the upper limb function using serious games at home. The aim of this study is to investigate the effect of MERLIN training on the upper limb function of patients with unilateral upper limb paresis in the chronic phase of stroke (> 6 months post stroke).

METHODS

Patients trained task specific serious games for three hours per week during six weeks using an unactuated version of a robotic device. Progress was monitored and game settings were tailored through telerehabilitation. Measurements were performed six weeks pre-intervention (T0), at the start (T1), end (T2) and six weeks post-intervention (T3). Primary outcome was the Wolf Motor Function Test (WMFT). Secondary outcomes were other arm function tests, quality of life, user satisfaction and motivation.

RESULTS

Twelve patients were included, ten completed the training. From start of the intervention to six weeks follow up, WMFT improved significantly with 3.8 points (p = .006), which is also clinically relevant. No significant changes in quality of life were observed. Patients were overall satisfied with the usability of the device. Comfort and the robustness of the system need further improvements.

CONCLUSION

Patients in the chronic phase of stroke significantly improved their upper limb function with the MERLIN training at home. Trial registration This study is registered at the Netherlands Trial Register (NL7535). Registered 18-02-2019, https://www.trialregister.nl/trial/7535 .

Serious Gaming Technology in Upper Extremity Rehabilitation: Scoping Review

Background

Serious gaming has increasingly gained attention as a potential new component in clinical practice. Specifically, its use in the rehabilitation of motor dysfunctions has been intensively researched during the past three decades.

Objective

The aim of this scoping review was to evaluate the current role of serious games in upper extremity rehabilitation, and to identify common methods and practice as well as technology patterns. This objective was approached via the exploration of published research efforts over time.

Methods

The literature search, using the PubMed and Scopus databases, included articles published from 1999 to 2019. The eligibility criteria were (i) any form of game-based arm rehabilitation; (ii) published in a peer-reviewed journal or conference; (iii) introduce a game in an electronic format; (iv) published in English; and (v) not a review, meta-analysis, or conference abstract. The search strategy identified 169 relevant articles.

Results

The results indicated an increasing research trend in the domain of serious gaming deployment in upper extremity rehabilitation. Furthermore, differences regarding the number of publications and the game approach were noted between studies that used commercial devices in their rehabilitation systems and those that proposed a custom-made robotic arm, glove, or other devices for the connection and interaction with the game platform. A particularly relevant observation concerns the evaluation of the introduced systems. Although one-third of the studies evaluated their implementations with patients, in most cases, there is the need for a larger number of participants and better testing of the rehabilitation scheme efficiency over time. Most of the studies that included some form of assessment for the introduced rehabilitation game mentioned user experience as one of the factors considered for evaluation of the system. Besides user experience assessment, the most common evaluation method involving patients was the use of standard medical tests. Finally, a few studies attempted to extract game features to introduce quantitative measurements for the evaluation of patient improvement.

Conclusions

This paper presents an overview of a significant research topic and highlights the current state of the field. Despite extensive attempts for the development of gamified rehabilitation systems, there is no definite answer as to whether a serious game is a favorable means for upper extremity functionality improvement; however, this certainly constitutes a supplementary means for motivation. The development of a unified performance quantification framework and more extensive experiments could generate richer evidence and contribute toward this direction.

A fairly simple mechatronic device for training human wrist motion

This article proposes a novel device for wrist motion rehabilitation. The proposed mechatronic architecture is based on a simple user-friendly design, which includes a mobile platform for hand support, which is operated by a single actuator. A dedicated assist-as-needed control is designed to operate the device for the required movements. The proposed control strategy is also integrated into a gaming software for stimulating the exercising by means of various interactions with patients. Experimental tests are carried out with 14 healthy subjects at the Physiotherapy Clinical Hospital of the Federal University of Uberlandia. Also, three patients with stroke have been enrolled in a pilot clinical testing. Each of the patients has been involved in four sessions per month with 15 min of assisted treatment. Results of experimental tests are analyzed in terms of improvements and amplitude gains for the flexion and extension wrist movements. Experimental results are reported as evidence for the feasibility and soundness of the proposed device as a tool to assist professionals in procedures of wrist rehabilitation.

Neurocognitive robot-assisted rehabilitation of hand function: a randomized control trial on motor recovery in subacute stroke

Background

Hand function is often impaired after stroke, strongly affecting the ability to perform daily activities. Upper limb robotic devices have been developed to complement rehabilitation therapy offered to persons who suffered a stroke, but they rarely focus on the training of hand sensorimotor function. The primary goal of this study was to evaluate whether robot-assisted therapy of hand function following a neurocognitive approach (i.e., combining motor training with somatosensory and cognitive tasks) produces an equivalent decrease in upper limb motor impairment compared to dose-matched conventional neurocognitive therapy, when embedded in the rehabilitation program of inpatients in the subacute stage after stroke.

Methods

A parallel-group, randomized controlled trial was conducted on subjects with subacute stroke receiving either conventional or robot-assisted neurocognitive hand therapy using a haptic device. Therapy was provided for 15, 45-min sessions over four weeks, nested within the standard therapy program. Primary outcome was the change from baseline in the upper extremity part of the Fugl-Meyer Assessment (FMA-UE) after the intervention, which was compared between groups using equivalence testing. Secondary outcome measures included upper limb motor, sensory and cognitive assessments, delivered therapy dose, as well as questionnaires on user technology acceptance.

Results

Thirty-three participants with stroke were enrolled. 14 subjects in the robot-assisted and 13 subjects in the conventional therapy group completed the study. At the end of intervention, week 8 and week 32, the robot-assisted/conventional therapy group improved by 7.14/6.85, 7.79/7.31, and 8.64/8.08 points on the FMA-UE, respectively, establishing that motor recovery in the robot-assisted group is non-inferior to that in the control group.

Conclusions

Neurocognitive robot-assisted therapy of hand function allows for a non-inferior motor recovery compared to conventional dose-matched neurocognitive therapy when performed during inpatient rehabilitation in the subacute stage. This allows the early familiarization of subjects with stroke to the use of such technologies, as a first step towards minimal therapist supervision in the clinic, or directly at home after hospital discharge, to help increase the dose of hand therapy for persons with stroke.

Trial registration

EUDAMED database (CIV-13-02-009921), clinicaltrials.gov (NCT02096445). Registered 26 March 2014 – Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT02096445

Design of a Two-DOFs Driving Mechanism for a Motion-Assisted Finger Exoskeleton

This paper presents a novel exoskeleton mechanism for finger motion assistance. The exoskeleton is designed as a serial 2-degrees-of-freedom wearable mechanism that is able to guide human finger motion. The design process starts by analyzing the motion of healthy human fingers by video motion tracking. The experimental data are used to obtain the kinematics of a human finger. Then, a graphic/geometric synthesis procedure is implemented for achieving the dimensional synthesis of the proposed novel 2 degrees of freedom linkage mechanism for the finger exoskeleton. The proposed linkage mechanism can drive the three finger phalanxes by using two independent actuators that are both installed on the back of the hand palm. A prototype is designed based on the proposed design by using additive manufacturing. Results of numerical simulations and experimental tests are reported and discussed to prove the feasibility and the operational effectiveness of the proposed design solution that can assist a wide range of finger motions with proper adaptability to a variety of human fingers.

Home-based telerehabilitation software systems for remote supervising: a systematic review

OBJECTIVES

In the past decade, with the ever-increasing growth of information and communication technologies, telerehabilitation, especially home-based rehabilitation (HBR), has been widely considered by researchers. Many software systems are developed to address HBR programs, which includes various functionalities. The aim of this study is to review the functional features of these systems designed for remote supervising of HBR programs.

METHODS

Scopus, PubMed, EMBASE, ISI Web of Science, Cochrane Library, IEEE Xplore Digital Library, and ProQuest databases were searched for English-language articles published between January 2008 and February 2018 to retrieve studies reported an home-based telerehabilitation software system aiming to remotely supervise HBR program.

RESULTS

A total of fifty studies that reported twenty-two unique systems met the inclusion criteria. Various functional features were identified including but not limited to exercise plan management, report/statistics generating, patient education, and task scheduling. Disorders or diseases addressed by these systems could mainly be grouped into five categories: musculoskeletal, neurological, respiratory, cardiovascular, and other health-related problems. Usability and acceptability, and clinical/patient outcomes were the most reported outcomes and data analysis was used by the majority of included studies to measure the outcomes.

CONCLUSIONS

Systems developed for supervising of HBR program are diverse. However, preliminary results of this review revealed that these systems share more or less common functionalities. However, further research is needed to determine the requirements, structure, and effectiveness of these systems in real-life settings.

Evaluation of the cognitive-motor performance of adults with Duchenne Muscular Dystrophy in a hand-related task

Duchenne muscular Dystrophy (DMD) is a progressive degenerative muscle disease, affecting, among others, the upper extremities. Effective hand rehabilitation can improve the hand function of people with DMD. To reach this goal, we first need to gain more insight into the hand cognitive-motor performance of people with DMD. This is the first study employing a systematic analysis on multi-finger, cognitive-motor performance of people with DMD. For this purpose, we propose an active dynamic visuo-motor task. The task employed six visual stimuli, a subset of which was activated at each trial. The stimuli were activated with a frequency of 1, 2, 3 and 4 Hz. Eight healthy participants and three participants with DMD performed the task. Additionally, the healthy participants performed seven sessions, and we assessed the training effects. Task-related cognitive-motor performance was evaluated using information transfer rate (ITR) and perceived workload. Regarding ITR, healthy participants performed significantly better than DMD participants; however, this was more evident for trials involving more than three fingers. Workload showed no difference between the healthy and the DMD groups. Healthy participants significantly improved their performance during training. Our results suggest that hand rehabilitation of people with DMD should consider multi-finger dynamic training. However, additional research with more people with DMD is needed for further generalization of our conclusions.

Development of an Integrated Actuated Hand Orthosis and Virtual Reality System for Home-Based Rehabilitation

Stroke survivors often require a lengthy and costly rehabilitation regimen to regain some of the hand function lost due to stroke. Financial, travel, and scheduling issues can limit access to clinical therapy, thereby depriving individuals of care. Interventions are needed which can extend from the clinic into the home. Home-based rehabilitation strategies, however, must promote sensorimotor learning while maintaining user engagement. Virtual reality, in combination with actuated orthoses, has the potential to provide solutions to these issues. The orthosis can facilitate appropriate therapy while the virtual reality can provide a conduit for maintaining human interaction and engagement in the home environment. In this paper, we describe the development of such an integrated system for hand and upper extremity rehabilitation.

Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients' Rehabilitation: Systematic Review

BACKGROUND

Robot-assisted therapy has become a promising technology in the field of rehabilitation for poststroke patients with motor disorders. Motivation during the rehabilitation process is a top priority for most stroke survivors. With current advancements in technology there has been the introduction of virtual reality (VR), augmented reality (AR), customizable games, or a combination thereof, that aid robotic therapy in retaining, or increasing the interests of, patients so they keep performing their exercises. However, there are gaps in the evidence regarding the transition from clinical rehabilitation to home-based therapy which calls for an updated synthesis of the literature that showcases this trend. The present review proposes a categorization of these studies according to technologies used, and details research in both upper limb and lower limb applications.

OBJECTIVE

The goal of this work was to review the practices and technologies implemented in the rehabilitation of poststroke patients. It aims to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies (VR, AR, or gamification) in improving activity and participation in poststroke survivors.

METHODS

A systematic search of the literature on exoskeleton robotics applied with any of the three technologies of interest (VR, AR, or gamification) was performed in the following databases: MEDLINE, EMBASE, Science Direct & The Cochrane Library. Exoskeleton-based studies that did not include any VR, AR or gamification elements were excluded, but publications from the years 2010 to 2017 were included. Results in the form of improvements in the patients' condition were also recorded and taken into consideration in determining the effectiveness of any of the therapies on the patients.

RESULTS

Thirty studies were identified based on the inclusion criteria, and this included randomized controlled trials as well as exploratory research pieces. There were a total of about 385 participants across the various studies. The use of technologies such as VR-, AR-, or gamification-based exoskeletons could fill the transition from the clinic to a home-based setting. Our analysis showed that there were general improvements in the motor function of patients using the novel interfacing techniques with exoskeletons. This categorization of studies helps with understanding the scope of rehabilitation therapies that can be successfully arranged for home-based rehabilitation.

CONCLUSIONS

Future studies are necessary to explore various types of customizable games required to retain or increase the motivation of patients going through the individual therapies.

Factors That Contribute to the Use of Stroke Self-Rehabilitation Technologies: A Review

Background

Stroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.

Objective

Our objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.

Methods

We performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.

Results

The criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.

Conclusions

We identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.

A facial expression controlled wheelchair for people with disabilities

BACKGROUND AND OBJECTIVES

In order to improve assistive technologies for people with reduced mobility, this paper develops a new intelligent real-time emotion detection system to control equipment, such as electric wheelchairs (EWC) or robotic assistance vehicles. Every year, degenerative diseases and traumas prohibit thousands of people to easily control the joystick of their wheelchairs with their hands. Most current technologies are considered invasive and uncomfortable such as those requiring the user to wear some body sensor to control the wheelchair.

METHODS

In this work, the proposed Human Machine Interface (HMI) provides an efficient hands-free option that does not require sensors or objects attached to the user's body. It allows the user to drive the wheelchair using its facial expressions which can be flexibly updated. This intelligent solution is based on a combination of neural networks (NN) and specific image preprocessing steps. First, the Viola-Jones combination is used to detect the face of the disability from a video. Subsequently, a neural network is used to classify the emotions displayed on the face. This solution called "The Mathematics Behind Emotion" is capable of classifying many facial expressions in real time, such as smiles and raised eyebrows, which are translated into signals for wheelchair control. On the hardware side, this solution only requires a smartphone and a Raspberry Pi card that can be easily mounted on the wheelchair.

RESULTS

Many experiments have been conducted to evaluate the efficiency of the control acquisition process and the user experience in driving a wheelchair through facial expressions. The classification accuracy can expect 98.6% and it can offer an average recall rate of 97.1%. Thus, all these experiments have proven that the proposed system is able of accurately recognizing user commands in real time. Indeed, the obtained results indicate that the suggested system is more comfortable and better adapted to severely disabled people in their daily lives, than conventional methods. Among the advantages of this system, we cite its real time ability to identify facial emotions from different angles.

CONCLUSIONS

The proposed system takes into account the patient's pathology. It is intuitive, modern, doesn't require physical effort and can be integrated into a smartphone or tablet. The results obtained highlight the efficiency and reliability of this system, which ensures safe navigation for the disabled patient.

A Systematic Review on Existing Measures for the Subjective Assessment of Rehabilitation and Assistive Robot Devices

The objective of the current study is to identify and classify outcome measures currently used for the assessment of rehabilitation or assistive robot devices. We conducted a systematic review of the literature using PubMed, MEDLINE, CIRRIE, and Scopus databases for studies that assessed rehabilitation or assistive robot devices from 1980 through January 2016. In all, 31 articles met all inclusion criteria. Tailor-made questionnaires were the most commonly used tool at 66.7%, while the great majority (93.9%) of the studies used nonvalidated instruments. The study reveals the absence of a standard scale which makes it difficult to compare the results from different researchers. There is a great need, therefore, for a valid and reliable instrument to be available for use by the intended end users for the subjective assessment of robot devices. The study concludes by identifying two scales that have been validated in general assistive technology devices and could support the scope of subjective assessment in rehabilitation or assistive robots (however, with limited coverage) and a new one called PYTHEIA, recently published. The latter intends to close the gap and help researchers and developers to evaluate, assess, and produce products that satisfy the real needs of the end users.

Strong relations of elbow excursion and grip strength with post-stroke arm function and activities: Should we aim for this in technology-supported training?

Objective

To investigate the relationships between an extensive set of objective movement execution kinematics of the upper extremity and clinical outcome measures in chronic stroke patients: at baseline and after technology-supported training at home.

Methods

Twenty mildly to severely affected chronic stroke patients participated in the baseline evaluation, 15 were re-evaluated after six weeks of intensive technology-supported or conventional arm/hand training at home. Grip strength, 3D motion analysis of a reach and grasp task, and clinical scales (Fugl-Meyer assessment (FM), Action Research Arm Test (ARAT) and Motor Activity Log (MAL)) were assessed pre- and post-training.

Results

Most movement execution parameters showed moderate-to-strong relationships with FM and ARAT, and to a smaller degree with MAL. Elbow excursion explained the largest amount of variance in FM and ARAT, together with grip strength. The only strong association after training was found between changes in ARAT and improvements in hand opening (conventional) or grip strength (technology-supported).

Conclusions

Elbow excursion and grip strength showed strongest association with post-stroke arm function and activities. Improved functional ability after training at home was associated with increased hand function. Addressing both reaching and hand function are indicated as valuable targets for (technological) treatment applications to stimulate functional improvements after stroke.

Development of a New Intelligent Joystick for People with Reduced Mobility

Despite the diversity of electric wheelchairs, many people with physical limitations and seniors have difficulty using their standard joystick. As a result, they cannot meet their needs or ensure safe travel. Recent assistive technologies can help to give them autonomy and independence. This work deals with the real-time implementation of an artificial intelligence device to overcome these problems. Following a review of the literature from previous work, we present the methodology and process for implementing our intelligent control system on an electric wheelchair. The system is based on a neural algorithm that overcomes problems with standard joystick maneuvers such as the inability to move correctly in one direction. However, this implies the need for an appropriate methodology to map the position of the joystick handle. Experiments on a real wheelchair are carried out with real patients of the Mohamed Kassab National Institute Orthopedic, Physical and Functional Rehabilitation Hospital of Tunis. The proposed intelligent system gives good results compared to the use of a standard joystick.

Impact of Targeted Assistance of Multiarticular Finger Musculotendons on the Coordination of Finger Muscles During Isometric Force Production

Neurological injuries often cause degraded motor control. While rehabilitation efforts typically focus on movement kinematics, abnormal muscle activation patterns are often the primary source of impairment. Muscle-based therapies are likely more effective than joint-based therapy. In this paper, we examined the feasibility of biomimetic input mimicking the action of human musculotendons in altering hand muscle coordination. Twelve healthy subjects produced a submaximal isometric dorsal fingertip force, while a custom actuator provided assistance mirroring the actions of either the extrinsic extensor or the intrinsic muscles of the index finger. The biomimetic inputs reduced the activation level of all task-related muscles, but the degree of change was different across the muscles, resulting in significant changes in their coordination (co-contraction ratios) and force-electromyography correlations. Each biomimetic assistance particularly increased the neural coupling between its targeted muscle and the antagonist muscle. Subjects appeared to fully take advantage of the assistance, as they provided minimal level of effort to achieve the task goal. The targeted biomimetic assistance may be used to retrain activation patterns post-stroke by effectively modulating connectivity between the muscles in the functional context and could be beneficial to restore hand function and reduce disability.

Intelligent Control Wheelchair Using a New Visual Joystick

A new control system of a hand gesture-controlled wheelchair (EWC) is proposed. This smart control device is suitable for a large number of patients who cannot manipulate a standard joystick wheelchair. The movement control system uses a camera fixed on the wheelchair. The patient's hand movements are recognized using a visual recognition algorithm and artificial intelligence software; the derived corresponding signals are thus used to control the EWC in real time. One of the main features of this control technique is that it allows the patient to drive the wheelchair with a variable speed similar to that of a standard joystick. The designed device "hand gesture-controlled wheelchair" is performed at low cost and has been tested on real patients and exhibits good results. Before testing the proposed control device, we have created a three-dimensional environment simulator to test its performances with extreme security. These tests were performed on real patients with diverse hand pathologies in Mohamed Kassab National Institute of Orthopedics, Physical and Functional Rehabilitation Hospital of Tunis, and the validity of this intelligent control system had been proved.

Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity

Background

People with chronic arm impairment should exercise intensely to regain their abilities, but frequently lack motivation, leading to poor rehabilitation outcome. One promising way to increase motivation is through interpersonal rehabilitation games, which allow patients to compete or cooperate together with other people. However, such games have mainly been evaluated with unimpaired subjects, and little is known about how they affect motivation and exercise intensity in people with chronic arm impairment.

Methods

We designed four different arm rehabilitation games that are played by a person with arm impairment and their unimpaired friend, relative or occupational therapist. One is a competitive game (both people compete against each other), two are cooperative games (both people work together against the computer) and one is a single-player game (played only by the impaired person against the computer). The games were played by 29 participants with chronic arm impairment, of which 19 were accompanied by their friend or relative and 10 were accompanied by their occupational therapist. Each participant played all four games within a single session. Participants’ subjective experience was quantified using the Intrinsic Motivation Inventory questionnaire after each game, as well as a final questionnaire about game preferences. Their exercise intensity was quantified using wearable inertial sensors that measured hand velocity in each game.

Results

Of the 29 impaired participants, 12 chose the competitive game as their favorite, 12 chose a cooperative game, and 5 preferred to exercise alone. Participants who chose the competitive game as their favorite showed increased motivation and exercise intensity in that game compared to other games. Participants who chose a cooperative game as their favorite also showed increased motivation in cooperative games, but not increased exercise intensity.

Conclusions

Since both motivation and intensity are positively correlated with rehabilitation outcome, competitive games have high potential to lead to functional improvement and increased quality of life for patients compared to conventional rehabilitation exercises. Cooperative games do not increase exercise intensity, but could still increase motivation of patients who do not enjoy competition. However, such games need to be tested in longer, multisession studies to determine whether the observed increases in motivation and exercise intensity persist over a longer period of time and whether they positively affect rehabilitation outcome.

Trial registration

The study is not a clinical trial. While human subjects are involved, they participate in a single-session evaluation of a rehabilitation game rather than a full rehabilitation intervention, and no health outcomes are examined.

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-017-0231-4) contains supplementary material, which is available to authorized users.

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 .

Design and pilot evaluation of competitive and cooperative exercise games for arm rehabilitation at home

People with chronic arm impairment should exercise intensely at home after completing their clinical rehabilitation program, but frequently lack motivation. To address this issue, we present a home rehabilitation system that motivates patients by allowing them to perform arm exercises together with friends or relatives in competitive and cooperative games. Inertial sensors are used to track the patient's arm and control the game. The system was tested with seven adults with arm impairment as well as their friends or spouses. They tested four exercise games (single-player, competitive and two different cooperative games) for 3 minutes each. Of the 7 participants, 4 preferred the competitive game, 2 preferred a cooperative game, and 1 preferred to exercise alone. Competition also increased exercise intensity (measured using inertial sensors) compared to exercising alone. Though preliminary, these results indicate that competitive exercise games could improve arm rehabilitation at home for survivors of neurological and orthopedic injuries.

Effects of training with a passive hand orthosis and games at home in chronic stroke: a pilot randomised controlled trial

OBJECTIVES

To compare user acceptance and arm and hand function changes after technology-supported training at home with conventional exercises in chronic stroke. Secondly, to investigate the relation between training duration and clinical changes.

DESIGN

A randomised controlled trial.

SETTING

Training at home, evaluation at research institute.

SUBJECTS

Twenty chronic stroke patients with severely to mildly impaired arm and hand function.

INTERVENTIONS

Participants were randomly assigned to six weeks (30 minutes per day, six days a week) of self-administered home-based arm and hand training using either a passive dynamic wrist and hand orthosis combined with computerised gaming exercises (experimental group) or prescribed conventional exercises from an exercise book (control group).

MAIN MEASURES

Main outcome measures are the training duration for user acceptance and the Action Research Arm Test for arm and hand function. Secondary outcomes are the Intrinsic Motivation Inventory, Fugl-Meyer assessment, Motor Activity Log, Stroke Impact Scale and grip strength.

RESULTS

The control group reported a higher training duration (189 versus 118 minutes per week, P = 0.025). Perceived motivation was positive and equal between groups ( P = 0.935). No differences in clinical outcomes over training between groups were found (P ⩾ 0.165). Changes in Box and Block Test correlated positively with training duration ( P = 0.001).

CONCLUSIONS

Both interventions were accepted. An additional benefit of technology-supported arm and hand training over conventional arm and hand exercises at home was not demonstrated. Training duration in itself is a major contributor to arm and hand function improvements.

A structured overview of trends and technologies used in dynamic hand orthoses

The development of dynamic hand orthoses is a fast-growing field of research and has resulted in many different devices. A large and diverse solution space is formed by the various mechatronic components which are used in these devices. They are the result of making complex design choices within the constraints imposed by the application, the environment and the patient's individual needs. Several review studies exist that cover the details of specific disciplines which play a part in the developmental cycle. However, a general collection of all endeavors around the world and a structured overview of the solution space which integrates these disciplines is missing. In this study, a total of 165 individual dynamic hand orthoses were collected and their mechatronic components were categorized into a framework with a signal, energy and mechanical domain. Its hierarchical structure allows it to reach out towards the different disciplines while connecting them with common properties. Additionally, available arguments behind design choices were collected and related to the trends in the solution space. As a result, a comprehensive overview of the used mechatronic components in dynamic hand orthoses is presented.

Development, design and validation of an assistive device for hand disabilities based on an innovative mechanism

In accordance with strict requirements of portability, cheapness, and modularity, an innovative assistive device for hand disabilities has been developed and validated. This robotic orthosis is designed to be a low-cost, portable hand exoskeleton to assist people with physical disabilities in their everyday lives. Referring to hand opening disabilities, the authors have developed a methodology which, by starting from the geometrical characteristics of the patient's hand, defines the novel kinematic mechanism that better fits to the finger trajectories. The authors have validated the proposed novel mechanism by carrying out a Hand Exoskeleton System (HES) prototype, based on a single-phalanx mechanism, cable driven. The testing phase of the real prototype with a patient is currently on going.

Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke

Background

Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke.

Methods

A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up.

Results

Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log.

Conclusions

Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings.

Trial registration

This study has been registered at the Netherlands Trial Registry (NTR): NTR3669.

Editorial: Foreword for special issue on rehabilitation robotics and human–robot interaction – ROBOTICA

The demand for motor rehabilitation is growing apace with the graying of the population. The utilization of robotic devices in sensorimotor rehabilitation therapy has received increased attention during the last decade. Despite the growing interest in using robotic devices for rehabilitation of sensorimotor function, their widespread use remains somewhat limited by a number of factors, including the assessment of the true cost-to-benefit ratio relative to other types of rehabilitation approaches and parameters that would optimize their long-term efficacy. Understanding human sensorimotor control and brain plasticity can provide insight into the design of robot hardware and controllers with the appropriate reference or desired output. On the other hand, the control of the physical interaction of the therapeutic device with the subject to effectively accelerate recovery is of paramount importance. This special issue focuses on the current state of knowledge about sensorimotor control and brain plasticity, models of sensorimotor functional recovery, and use of intelligent robot controllers to provide robotic-assisted therapy for motor rehabilitation.