Determining Factors that Influence Adoption of New Post-Stroke Sensorimotor Rehabilitation Devices in the USA

Wearable Sensor to Monitor Quality of Upper Limb Task Practice for Stroke Survivors at Home

Many stroke survivors experience persistent upper extremity impairment that limits performance in activities of daily living. Upper limb recovery requires high repetitions of task-specific practice. Stroke survivors are often prescribed task practices at home to supplement rehabilitation therapy. A poor quality of task practices, such as the use of compensatory movement patterns, results in maladaptive neuroplasticity and suboptimal motor recovery. There currently lacks a tool for the remote monitoring of movement quality of stroke survivors' task practices at home. The objective of this study was to evaluate the feasibility of classifying movement quality at home using a wearable IMU. Nineteen stroke survivors wore an IMU sensor on the paretic wrist and performed four functional upper limb tasks in the lab and later at home while videorecording themselves. The lab data served as reference data to classify home movement quality using dynamic time warping. Incorrect and correct movement quality was labeled by a therapist. The home task practice movement quality was classified with an accuracy of 92% and F1 score of 0.95 for all tasks combined. Movement types contributing to misclassification were further investigated. The results support the feasibility of a home movement quality monitoring system to assist with upper limb rehabilitation post stroke.

Effect of Using TheraBracelet on Grasping versus Reaching in Poststroke Rehabilitation

A peripheral sensory stimulation named TheraBracelet has recently been shown to have a potential to improve gross manual dexterity following stroke. Upper limb function requires both reach and grasp. It is unknown whether TheraBracelet affects one more than other. The objective of this study was to determine whether TheraBracelet improves reaching versus grasping. In a pilot randomized controlled trial, persons with stroke received TheraBracelet (treatment) or no stimulation (control) during task practice therapy (n = 6/group). Effects of TheraBracelet on reaching versus grasping were determined using breakdown of movement times in the Box and Block Test video recordings. Improvements in movement times for the treatment compared with control group were more pronounced for grasping than for reaching at both post and follow-up time points. TheraBracelet may be beneficial for persons with grasping deficits. This knowledge can guide clinicians for targeted use of TheraBracelet, resulting in effective implementation of the new treatment.

Development and evaluation of an efficient training program to facilitate the adoption of a novel neurorehabilitation device

Many rehabilitation devices are not adopted by therapists in practice. One major barrier is therapists' limited time and resources to get training. The objective of this study was to develop/evaluate an efficient training program for a novel rehabilitation device. The program was developed based on structured interviews with seven therapists for training preference and composed of asynchronous and in-person trainings following efficient teaching methods. The training program was evaluated for six occupational therapy doctoral students and six licensed therapists in neurorehabilitation practice. Training effectiveness was evaluated in a simulated treatment session in which 3 trainees shifted their roles among therapist applying the device, client, and peer assessor. In results, 11 of the 12 trainees passed the assessment of using the device in simulated treatment sessions. One trainee did not pass because s/he did not plug in the device to charge at the end. The in-person training fit within 1-h lunch break. All trainees perceived that they could effectively use the device in their practice and both asynchronous and in-person training easily fit into their schedule. This project serves as an example for development of an efficient and effective training program for a novel rehabilitation device to facilitate clinical adoption.

Effect of Self-Directed Home Therapy Adherence Combined with TheraBracelet on Poststroke Hand Recovery: A Pilot Study

Hand impairment is a common consequence of stroke, resulting in long-term disability and reduced quality of life. Recovery may be augmented through self-directed therapy activities at home, complemented by the use of rehabilitation devices such as peripheral sensory stimulation. The objective of this study was to determine the effect of adherence to self-directed therapy and the use of TheraBracelet (subsensory random-frequency vibratory stimulation) on hand function for stroke survivors. In a double-blind, randomized controlled pilot trial, 12 chronic stroke survivors were assigned to a treatment or control group (n = 6/group). All participants were instructed to perform 200 repetitions of therapeutic hand tasks 5 days/week while wearing a wrist-worn device 8 hours/day for 4 weeks. The treatment group received TheraBracelet vibration from the device, while the control group received no vibration. Home task repetition adherence and device wear logs, as well as hand function assessment (Stroke Impact Scale Hand domain), were obtained weekly. Repetition adherence was comparable between groups but varied among participants. Participants wore the device to a greater extent than adhering to completing repetitions. A linear mixed model analysis showed a significant interaction between repetition and group (p = 0.01), with greater adherence resulting in greater hand function change for the treatment group (r = 0.94; R ² = 0.88), but not for the control group. Secondary analysis revealed that repetition adherence was greater for those with lower motor capacity and greater self-efficacy at baseline. This pilot study suggests that adherence to self-directed therapy at home combined with subsensory stimulation may affect recovery outcomes in stroke survivors. This trial is registered with NCT04026399.

Quantitative measurement of resistance force and subsequent attenuation during passive isokinetic extension of the wrist in patients with mild to moderate spasticity after stroke

Background

Spasticity is evaluated by measuring the increased resistance to passive movement, primarily by manual methods. Few options are available to measure spasticity in the wrist more objectively. Furthermore, no studies have investigated the force attenuation following increased resistance. The aim of this study was to conduct a safe quantitative evaluation of wrist passive extension stiffness in stroke survivors with mild to moderate spastic paresis using a custom motor-controlled device. Furthermore, we wanted to clarify whether the changes in the measured values could quantitatively reflect the spastic state of the flexor muscles involved in the wrist stiffness of the patients.

Materials and methods

Resistance forces were measured in 17 patients during repetitive passive extension of the wrist at velocities of 30, 60, and 90 deg/s. The Modified Ashworth Scale (MAS) in the wrist and finger flexors was also assessed by two skilled therapists and their scores were averaged (i.e., average MAS) for analysis. Of the fluctuation of resistance, we focused on the damping just after the peak forces and used these for our analysis. A repeated measures analysis of variance was conducted to assess velocity-dependence. Correlations between MAS and damping parameters were analyzed using Spearman’s rank correlation.

Results

The damping force and normalized value calculated from damping part showed significant velocity-dependent increases.

There were significant correlations (ρ = 0.53–0.56) between average MAS for wrist and the normalized value of the damping part at 90 deg/s. The correlations became stronger at 60 deg/s and 90 deg/s when the MAS for finger flexors was added to that for wrist flexors (ρ = 0.65–0.68).

Conclusions

This custom-made isokinetic device could quantitatively evaluate spastic changes in the wrist and finger flexors simultaneously by focusing on the damping part, which may reflect the decrease in resistance we perceive when manually assessing wrist spasticity using MAS.

Trial registration UMIN Clinical Trial Registry, as UMIN000030672, on July 4, 2018

Evaluation of the implementation of Armeo®Spring in a specialized neurorehabilitation center

Rehabilitation of the upper extremity (UE) is an essential part of the process following an acquired brain injury, where robot technologies have the potential of making the rehabilitation more intensive and effective. However, the implementation of robot technologies in a clinical setting can be complicated and not always successful. The aim of this study was to evaluate the implementation of the robot technology Armeo®Spring (Hocoma, Volketswil, Switzerland) at a specialized neurorehabilitation center, and to propose a list of actions for further implementation of the technology.The Study, Act and Plan phases of the Plan-Do-Study-Act (PDSA) model for structuring technology implementations was applied as the methodological framework in this study. In the Study-phase, nine semi-structured interviews with therapists, using Armeo®Spring, were conducted to evaluate the current implementation. In the Act-phase, a workshop was held with 13 participants to discuss the findings of the Study-phase and to find possible solutions to the identified problems. The results were incorporated into a list of actions (Plan-phase) for further implementation of Armeo®Spring.Facilitating and inhibiting factors for the implementation of Armeo®Spring were identified. Facilitating factors were the practical "hands-on" approach during training, support from the management, support and sparring with colleagues as well as a positive work culture. The inhibiting factors were related to the retention of the therapists' acquired competencies, the identification of the type of patient that can benefit from this form of training, challenges due to the technical use of Armeo®Spring, and prioritization of the rehabilitation needs of the patients.Several solutions were proposed in the Act-phase, which subsequently resulted in eight concrete actions to facilitate the further implementation of Armeo®Spring. It is expected that these actions will contribute to the further implementation of Armeo®Spring at the neurorehabilitation center. As a first step, an Armeo®Spring group with therapists from all relevant wards was established.

Effect of novel training to normalize altered finger force direction post-stroke: study protocol for a double-blind randomized controlled trial

BACKGROUND

Functional task performance requires proper control of both movement and force generation in three-dimensional space, especially for the hand. Control of force in three dimensions, however, is not explicitly treated in current physical rehabilitation. To address this gap in treatment, we have developed a tool to provide visual feedback on three-dimensional finger force. Our objective is to examine the effectiveness of training with this tool to restore hand function in stroke survivors.

METHODS

Double-blind randomized controlled trial. All participants undergo 18 1-h training sessions to practice generating volitional finger force of various target directions and magnitudes. The experimental group receives feedback on both force direction and magnitude, while the control group receives feedback on force magnitude only. The primary outcome is hand function as measured by the Action Research Arm Test. Other outcomes include the Box and Block Test, Stroke Impact Scale, ability to direct finger force, muscle activation pattern, and qualitative interviews.

DISCUSSION

The protocol for this clinical trial is described in detail. The results of this study will reveal whether explicit training of finger force direction in stroke survivors leads to improved motor control of the hand. This study will also improve the understanding of neuromuscular mechanisms underlying the recovery of hand function.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03995069 . Registered on June 21, 2019.

Concomitant sensory stimulation during therapy to enhance hand functional recovery post stroke

Background

Post-stroke hand impairment is prevalent and persistent even after a full course of rehabilitation. Hand diminishes stroke survivors’ abilities for activities of daily living and independence. One way to improve treatment efficacy is to augment therapy with peripheral sensory stimulation. Recently, a novel sensory stimulation, TheraBracelet, has been developed in which imperceptible vibration is applied during task practice through a wrist-worn device. The objective of this trial is to determine if combining TheraBracelet with hand task practice is superior to hand task practice alone.

Methods

A double-blind randomized controlled trial will be used. Chronic stroke survivors will undergo a standardized hand task practice therapy program (3 days/week for 6 weeks) while wearing a device on the paretic wrist. The device will deliver TheraBracelet vibration for the treatment group and no vibration for the control group. The primary outcome is hand function measured by the Wolf Motor Function Test. Other outcomes include the Box and Block Test, Action Research Arm Test, upper extremity use in daily living, biomechanical measure of the sensorimotor grip control, and EEG-based neural communication.

Discussion

This research will determine clinical utility of TheraBracelet to guide future translation. The TheraBracelet stimulation is delivered via a wrist-worn device, does not interfere with hand motion, and can be easily integrated into clinical practice. Enhancing hand function should substantially increase stroke survivors' independence and quality of life and reduce caregiver burden.

Trial registration

NCT04569123. Registered on September 29, 2020