Rehab-let: touchscreen tablet for self-training impaired dexterity post stroke: study protocol for a pilot randomized controlled trial

Effectiveness of a Telerehabilitation Evidence-Based Tablet App for Rehabilitation in Traumatic Bone and Soft Tissue Injuries of the Hand, Wrist, and Fingers

OBJECTIVE

To assess whether feedback-guided exercises performed on a tablet touchscreen improve clinical recovery and reduce health care usage more than the conventional home exercise program prescribed on paper in patients with bone and soft tissue injuries of the wrist, hand, and/or fingers treated by public health services.

DESIGN

A multicenter assessor-blinded, parallel, 2-group controlled trial.

SETTING

Trauma and rehabilitation services of 4 hospitals.

PARTICIPANTS

Six hundred sixty-three patients with limited functional ability due to bone and soft tissue injuries of the wrist, hand, and/or fingers (N=663).

INTERVENTIONS

The experimental group received a home exercise program using a tablet-based application with feedback, monitoring, and progression; the control group received an evidence-based home exercise program on paper.

MAIN OUTCOME MEASURES

The primary outcome was functional ability through Patient Rated Wrist Evaluation for wrist conditions and the short version of Disabilities of the Arm, Shoulder and Hand for all other hand pathologies. Secondary outcomes included dexterity, pain intensity, grip strength, and health care usage (number of patients referred to rehabilitation service and number of clinical appointments).

RESULTS

The experimental group showed a significant improvement on the Patient Rated Wrist Evaluation (P=.001) and the short version of Disabilities of the Arm, Shoulder and Hand (P=.001) with medium effect sizes (η2=0.066-0.067) when compared with the control group. Regarding health care usage, the experimental group presented a reduction of 41% in the rate of referrals to face-to-face rehabilitation service consultations, a reduction of rehabilitation consultations (mean difference=-1.64; 95% confidence interval, -2.64 to -0.65) and physiotherapy sessions (mean difference=-8.52, 95% confidence interval, -16.92 to -0.65) compared to the control group.

CONCLUSIONS

In patients with bone and soft tissue injuries of the wrist, hand, and/or fingers, prescribing feedback-guided exercises performed on a tablet touchscreen was more effective for improving patients' functional ability and reduced the number of patients referred to rehabilitation consultation and number of clinical appointments.

Evaluating the Dissemination and Implementation Impact of a Rehabilitation Intervention: The Graded Repetitive Arm Supplementary Program (GRASP)

Purpose

To evaluate the dissemination and implementation impacts of a rehabilitation intervention.

Methods

Systematic evaluation of data sources including academic publishing metrics, publications, and surveys was used to describe the dissemination and implementation impact of the graded repetitive arm supplementary program (GRASP). Three categories in the Payback Framework were evaluated: knowledge production and dissemination, benefits to future research and research use, and real-world uptake and implementation.

Results

In the Knowledge production and dissemination category, seven publications, authored by the GRASP research team, were associated with the GRASP, and there were approximately 17,000 download counts of GRASP manuals from the website from 120 countries. In the Benefits to future research and research use category, 15 studies and 8 registered clinical trials, authored by researchers outside of the GRASP team, have used GRASP as an intervention. In the real-world uptake and implementation category, GRASP has informed recommendations in 2 clinical guidelines and 20 review papers, and had high implementation uptake (e.g., 35% [53/154] of UK therapists surveyed had used GRASP; 95% [649/681] who downloaded GRASP had used it). More than 75% of those who had used GRASP identified that GRASP provides more intensity in upper extremity rehabilitation, is evidence-based and easy to implement, and the equipment and manual are easy to obtain.

Conclusion

The Payback Framework is useful to evaluate the dissemination and implementation impacts of a rehabilitation intervention. GRASP has been implemented extensively in clinical practice and community in a relatively short time since it has been developed.

Combining physical and virtual worlds for motor-cognitive training interventions: Position paper with guidelines on technology classification in movement-related research

Efficient movements require intact motor and cognitive function. There is a growing literature on motor-cognitive interventions to improve the overall quality of life of healthy or diseased older people. For such interventions, novel technological advances are crucial not only in terms of motivation but also to improve the user experience in a multi-stimuli world, usually offered as a mixture of real and virtual environments. This article provides a classification system for movement-related research dealing with motor-cognitive interventions performed in different extents of a virtual environment. The classification is divided into three categories: (a) type of digital device with the associated degree of immersiveness provided; (b) presence or absence of a human-computer interaction; and (c) activity engagement during training, defined by activity >1.5 Metabolic Equivalent of task. Since virtual reality (VR) often categorizes different technologies under the same term, we propose a taxonomy of digital devices ranging from computer monitors and projectors to head-mounted VR technology. All immersive technologies that have developed rapidly in recent years are grouped under the umbrella term Extended Reality (XR). These include augmented reality (AR), mixed reality (MR), and VR, as well as all technologies that have yet to be developed. This technology has potential not only for gaming and entertainment, but also for research, motor-cognitive training programs, rehabilitation, telemedicine, etc. This position paper provides definitions, recommendations, and guidelines for future movement-related interventions based on digital devices, human-computer interactions, and physical engagement to use terms more consistently and contribute to a clearer understanding of their implications.

A novel tablet-based application for assessment of manual dexterity and its components: a reliability and validity study in healthy subjects

BACKGROUND

We developed five tablet-based tasks (applications) to measure multiple components of manual dexterity.

AIM

to test reliability and validity of tablet-based dexterity measures in healthy participants.

METHODS

Tasks included: (1) Finger recognition to assess mental rotation capacity. The subject taps with the finger indicated on a virtual hand in three orientations (reaction time, correct trials). (2) Rhythm tapping to evaluate timing of finger movements performed with, and subsequently without, an auditory cue (inter-stimulus interval). (3) Multi-finger tapping to assess independent finger movements (reaction time, correct trials, unwanted finger movements). (4) Sequence tapping to assess production and memorization of visually cued finger sequences (successful taps). (5) Line-tracking to assess movement speed and accuracy while tracking an unpredictably moving line on the screen with the fingertip (duration, error). To study inter-rater reliability, 34 healthy subjects (mean age 35 years) performed the tablet tasks twice with two raters. Relative reliability (Intra-class correlation, ICC) and absolute reliability (Standard error of measurement, SEM) were established. Task validity was evaluated in 54 healthy subjects (mean age 49 years, range: 20-78 years) by correlating tablet measures with age, clinical dexterity assessments (time taken to pick-up objects in Box and Block Test, BBT and Moberg Pick Up Test, MPUT) and with measures obtained using a finger force-sensor device.

RESULTS

Most timing measures showed excellent reliability. Poor to excellent reliability was found for correct trials across tasks, and reliability was poor for unwanted movements. Inter-session learning occurred in some measures. Age correlated with slower and more variable reaction times in finger recognition, less correct trials in multi-finger tapping, and slower line-tracking. Reaction times correlated with those obtained using a finger force-sensor device. No significant correlations between tablet measures and BBT or MPUT were found. Inter-task correlation among tablet-derived measures was weak.

CONCLUSIONS

Most tablet-based dexterity measures showed good-to-excellent reliability (ICC ≥ 0.60) except for unwanted movements during multi-finger tapping. Age-related decline in performance and association with finger force-sensor measures support validity of tablet measures. Tablet-based components of dexterity complement conventional clinical dexterity assessments. Future work is required to establish measurement properties in patients with neurological and psychiatric disorders.

Personalized Touch-Based Exergame System for Unilateral and Bilateral Rehabilitation Training

Background: Natural and intuitive interfaces that monitor and promote upper limb task-specific training need to be developed. This article presents the development and testing of a touch-based game system for training and assessment of unilateral (ULR) and bilateral (BLR) reaching movements. Interaction becomes intuitive and simple by introducing in-game touch and pressure onto virtual targets projected on a custom-made large touch panel. Materials and Methods: A custom-made App integrates exergames and a biomechanical model with advanced algorithms for movement analysis. It processes and manages data from a motion-tracking sensor and a large touch panel equipped with 1222 (26 × 47) piezoresistive sensors, including high-speed readout electronics and algorithms to measure touch points and contact forces during fingertip interaction. An experiment was conducted to evaluate the experience, motivation, and movements of healthy and stroke subjects when interacting with the proposed system. The panel height, dispersion of virtual targets, and required contact force were customized based on motor skills of each group of subjects. Results: Both groups of subjects showed high level of motivation and user experience when interacting with the virtual environments. Stroke subjects performed the task slower and traveled a similar path length than healthy subjects, but with shorter range of motion. The mechanical work and potential energy profiles of both groups are consistent with those achieved when reaching real objects. Conclusions: The proposed contact-based exergames are a feasible solution for performing natural and intuitive therapeutic ULR and BLR exercises. They elicit appropriate reaching movements and contact forces in healthy and stroke subjects. The spatial and temporal attributes of the proposed solution can be customized to influence the movement and energy expenditure of specific joints.

Who, what, when, where, why, and how: a systematic review of the quality of post-stroke cognitive rehabilitation protocols

BACKGROUND

. Rehabilitation research findings are not routinely incorporated into clinical practice. A key barrier is the quality of reporting in the original study, including who provided the intervention, what it entailed, when and where it occurred, how patient outcomes were monitored, and why the intervention was efficacious.

OBJECTIVES

. To facilitate clinical implementation of post-stroke cognitive rehabilitation research, we undertook a review to examine the quality of intervention reporting in this literature.

METHODS

. Four databases were systematically searched, identifying 27 randomised controlled trials of post-stroke cognitive rehabilitation. The quality of intervention protocol descriptions in each study was independently rated by 2 of the authors using the 12-item Template for Intervention Description and Replication (TIDieR) checklist.

RESULTS

.Why, when, and where items were reported in more than 70% of interventions, what materials and procedures used was described in 50% to 70%, how items were described in approximately half of the interventions, and who provided interventions was reported in 22% of studies. No study addressed all 12 TIDieR items. "Active ingredients" that may further characterise an intervention and the potential mechanisms of action included restorative training, massed practice, feedback, and tailoring demands (present in approximately 50% of studies).

CONCLUSIONS

. Descriptions of intervention protocols are variable and frequently insufficient, thereby restricting the ability to understand, replicate, and implement evidence-based cognitive rehabilitation. Use of reporting checklists to address this barrier to research translation is a readily achievable and effective means to advance post-stroke care.

Dexteria app. therapy versus conventional hand therapy in stroke

Purpose

Hand impairment post-stroke is a very common and important rehabilitation goal for functional independence. Advanced therapy options such as an app. therapy provides repetitive training, which may be beneficial for improving fine motor function. This study aims to evaluate the effect of app-based therapy compared to conventional hand therapy in improving dexterity in individuals with stroke.

Methodology

In total, 39 individuals within the first year of stroke with Brunnstrom stage of hand recovery IV to VI were randomly divided into three groups. All three groups received 60 min of therapy for 21 sessions over a period of 30 days. Group A received conventional hand therapy; Group B received app. therapy, while Group C received conventional therapy along with the app. therapy. All participants were assessed on the Nine-Hole Peg Test and Jebsen–Taylor Hand Function Test at the beginning and after completion of 21 sessions of intervention. Kruskal–Wallis (H) test and Wilcoxon test were used for statistical analysis.

Results

All three groups improved on hand function post-treatment. However, Group C demonstrated significant improvement with 16%–58% increase in hand function performance on outcome measures (p < 0.05).

Findings

Findings of the present study demonstrate improvement in dexterity with the app. therapy and combination therapy, in comparison to conventional therapy alone in individuals with stroke.

Originality

This experimental study focuses the first time on a structured protocol using an enabling technology adjunct to conventional physical therapy to improve hand function in individuals with stroke, which opens up the further scope in Neurorehabilitation.

Peer review

The peer review history for this article is available at: https://publons.com/publon/10.1108/ILT-04-2020-0144/

Successful performance of basic gestures in tablet technology in post stroke patients: A feasibility study

BACKGROUND

Tablet technology is a promising tool for assisting therapeutic strategies in stroke rehabilitation. However, it is not clear whether the basic gestures (e.g. click, double-click) are feasible.

OBJECTIVE

This study aimed to assess the successful performance of gestures and associated factors.

METHODS

This cross-sectional study was conducted at a rehabilitation center in Austria. The successful tablet use was checked on a Samsung Galaxy Tab 4 (10.1 Wi-Fi 25.6 cm; 10.1 Zoll) with a specifically developed app. To identify factors associated with successful use, impairments in activities of daily living (Barthel index), cognitive functions (Montreal Cognitive Assessment, MoCA), motor functions (Nine-Hole Peg Test), and grip strength (handgrip dynamometer) were assessed.

RESULTS

One hundred and twenty-nine participants were analyzed, whereof 53.5% had a paretic upper limp and 69.2% were able to perform all gestures with at least one hand. Factors associated with successful use were higher Barthel index (OR: 1.06; 95% CI = 1.01-1.11) and MoCA (OR: 1.21; 95% CI = 1.01-1.44), whereas lower age (OR: 0.91; 95% CI = 0.83-0.99) and a paretic hand (OR: 0.12; 95% CI = 0.01-0.99) were associated with a lesser likelihood. Additionally, 18.6% successfully performed all gestures with the paretic hand, whereof 74% could not perform the double-click and 77.0% were not able to zoom.

CONCLUSIONS

The majority of stroke patients are able to perform the basic gestures on a tablet with at least one hand, but only few patients with paresis could do them. Gestures like double-clicking and zooming should be avoided when designing apps for rehabilitation, as especially these were found difficult.

Emergency management of stroke in the era of mechanical thrombectomy

Emergency management of stroke has been directed at the delivery of recombinant tissue plasminogen activator (tPA) in a timely fashion. Because of the many limitations attached to the delivery of tPA and the perceived benefits accrued to tPA, its use has been limited. Mechanical thrombectomy, a far superior therapy for the largest and most disabling strokes, large vessel occlusions (LVOs), has changed the way acute strokes are managed. Aside from the rush to deliver tPA, there is now a need to identify LVO and refer those patients with LVO to physicians and facilities capable of delivering urgent thrombectomy. Other parts of emergency department management of stroke are directed at identifying and mitigating risk factors for future strokes and at preventing further damage from occurring. We review here the most recent literature supporting these advances in stroke care and present a framework for understanding the role that emergency physicians play in acute stroke care.

Development of an English-language version of a Japanese iPad application to facilitate collaborative goal setting in rehabilitation: a Delphi study and field test

OBJECTIVE

This study aimed to investigate the content of an English-language version of a Japanese iPad application designed to facilitate shared decision-making around goal setting in rehabilitation: Aid for Decision-making in Occupational Choice-English (ADOC-E).

DESIGN

Phase 1: Delphi methods to reach consensus with an international group of expert occupational therapists on the text and images in ADOC-E. Phase 2: Testing correct recognition (unprompted and prompted) of images in ADOC-E by health service users in inpatient rehabilitation and residential care.

SETTING

Phase 1: International, online. Phase 2: Three healthcare services in New Zealand-(1) a residential rehabilitation service for traumatic brain injury, (2) a nursing home for frail older adults and (3) an inpatient rehabilitation ward in a public hospital.

PARTICIPANTS

Phase 1: Fourteen experienced occupational therapists from New Zealand (4), Australia (4), UK (2) and USA (4). Phase 2: Twenty-four rehabilitation and residential care service users (10 men, 14 women; 20-95 years; Mini-Mental State Exam scores 13-30).

RESULTS

Four Delphi rounds were required to reach consensus with the experienced occupational therapists on the content of ADOC-E, ending with 100 items covering daily activities that people do and social roles they participate in. Ninety-five per cent (95/100) of ADOC-E items could each be correctly identified by over 80% of service user participants with either unprompted or prompted recognition.

CONCLUSION

While a few of the more abstract concepts in ADOC-E (related to complex social roles) were less likely to be correctly recognised by all participants, the text and images ADOC-E were deemed to be fit for purpose overall and ready for future clinical testing.

Use of Dexteria application to improve fine motor coordination in the nondominant hand

The authors report improved fine motor coordination when using Dexteria with a healthy population. Technology may improve patient engagement and participation when incorporated into treatment programs. - Kristin Valdes, OTD, OT, CHT, Practice Forum Editor, Journal of Hand Therapy.

iPad Use in Stroke Neuro-Rehabilitation

Neuro-rehabilitation services are essential in reducing post-stroke impairments, enhancing independence, and improving recovery in hospital and post-discharge. However these services are therapist-dependent and resource intensive. Patients’ disengagement and boredom in stroke units are common which adversely affect functional and psychological outcomes. Novel techniques such as use of iPads™ are increasingly researched to overcome such challenges. The aim of this review is to determine the feasibility, effectiveness, acceptability, and barriers to the use of iPads™ in stroke neuro-rehabilitation. Four databases and manual literature search were used to identify published studies using the terms “iPad”, “Stroke”, and “neuro-rehabilitation”. Studies were included in accordance with the review selection criteria. A total of 16 articles were included in the review. The majority of the studies focused on iPads use in speech and language therapy. Although of small scale, the studies highlighted that iPads are feasible, have the potential to improve rehabilitation outcomes, and can improve patient’s social isolation. Patients’ stroke severity and financial limitations are some of the barriers highlighted in this review. This review presents preliminary data supportive for the use of iPad technology in stroke neuro-rehabilitation. However, further research is needed to determine impact on rehabilitation goals acquisition, clinical efficacy, and cost-efficiency.

RecoverNow: Feasibility of a Mobile Tablet-Based Rehabilitation Intervention to Treat Post-Stroke Communication Deficits in the Acute Care Setting

BACKGROUND

Approximately 40% of patients diagnosed with stroke experience some degree of aphasia. With limited health care resources, patients' access to speech and language therapies is often delayed. We propose using mobile-platform technology to initiate early speech-language therapy in the acute care setting. For this pilot, our objective was to assess the feasibility of a tablet-based speech-language therapy for patients with communication deficits following acute stroke.

METHODS

We enrolled consecutive patients admitted with a stroke and communication deficits with NIHSS score ≥1 on the best language and/or dysarthria parameters. We excluded patients with severe comprehension deficits where communication was not possible. Following baseline assessment by a speech-language pathologist (SLP), patients were provided with a mobile tablet programmed with individualized therapy applications based on the assessment, and instructed to use it for at least one hour per day. Our objective was to establish feasibility by measuring recruitment rate, adherence rate, retention rate, protocol deviations and acceptability.

RESULTS

Over 6 months, 143 patients were admitted with a new diagnosis of stroke: 73 had communication deficits, 44 met inclusion criteria, and 30 were enrolled into RecoverNow (median age 62, 26.6% female) for a recruitment rate of 68% of eligible participants. Participants received mobile tablets at a mean 6.8 days from admission [SEM 1.6], and used them for a mean 149.8 minutes/day [SEM 19.1]. In-hospital retention rate was 97%, and 96% of patients scored the mobile tablet-based communication therapy as at least moderately convenient 3/5 or better with 5/5 being most "convenient".

CONCLUSIONS

Individualized speech-language therapy delivered by mobile tablet technology is feasible in acute care.

Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke?

Motor-training software on tablets or smartphones (Apps) offer a low-cost, widely-available solution to supplement arm physiotherapy after stroke. We assessed the proportions of hemiplegic stroke patients who, with their plegic hand, could meaningfully engage with mobile-gaming devices using a range of standard control-methods, as well as by using a novel wireless grip-controller, adapted for neurodisability. We screened all newly-diagnosed hemiplegic stroke patients presenting to a stroke centre over 6 months. Subjects were compared on their ability to control a tablet or smartphone cursor using: finger-swipe, tap, joystick, screen-tilt, and an adapted handgrip. Cursor control was graded as: no movement (0); less than full-range movement (1); full-range movement (2); directed movement (3). In total, we screened 345 patients, of which 87 satisfied recruitment criteria and completed testing. The commonest reason for exclusion was cognitive impairment. Using conventional controls, the proportion of patients able to direct cursor movement was 38–48%; and to move it full-range was 55–67% (controller comparison: p>0.1). By comparison, handgrip enabled directed control in 75%, and full-range movement in 93% (controller comparison: p<0.001). This difference between controllers was most apparent amongst severely-disabled subjects, with 0% achieving directed or full-range control with conventional controls, compared to 58% and 83% achieving these two levels of movement, respectively, with handgrip. In conclusion, hand, or arm, training Apps played on conventional mobile devices are likely to be accessible only to mildly-disabled stroke patients. Technological adaptations such as grip-control can enable more severely affected subjects to engage with self-training software.

Development of a Portable Motor Learning Laboratory (PoMLab)

Most motor learning experiments have been conducted in a laboratory setting. In this type of setting, a huge and expensive manipulandum is frequently used, requiring a large budget and wide open space. Subjects also need to travel to the laboratory, which is a burden for them. This burden is particularly severe for patients with neurological disorders. Here, we describe the development of a novel application based on Unity3D and smart devices, e.g., smartphones or tablet devices, that can be used to conduct motor learning experiments at any time and in any place, without requiring a large budget and wide open space and without the burden of travel on subjects. We refer to our application as POrtable Motor learning LABoratory, or PoMLab. PoMLab is a multiplatform application that is available and sharable for free. We investigated whether PoMLab could be an alternative to the laboratory setting using a visuomotor rotation paradigm that causes sensory prediction error, enabling the investigation of how subjects minimize the error. In the first experiment, subjects could adapt to a constant visuomotor rotation that was abruptly applied at a specific trial. The learning curve for the first experiment could be modeled well using a state space model, a mathematical model that describes the motor leaning process. In the second experiment, subjects could adapt to a visuomotor rotation that gradually increased each trial. The subjects adapted to the gradually increasing visuomotor rotation without being aware of the visuomotor rotation. These experimental results have been reported for conventional experiments conducted in a laboratory setting, and our PoMLab application could reproduce these results. PoMLab can thus be considered an alternative to the laboratory setting. We also conducted follow-up experiments in university physical education classes. A state space model that was fit to the data obtained in the laboratory experiments could predict the learning curves obtained in the follow-up experiments. Further, we investigated the influence of vibration function, weight, and screen size on learning curves. Finally, we compared the learning curves obtained in the PoMLab experiments to those obtained in the conventional reaching experiments. The results of the in-class experiments show that PoMLab can be used to conduct motor learning experiments at any time and place.

What Do Stroke Patients Look for in Game-Based Rehabilitation: A Survey Study

Stroke is one of the most common causes of physical disability, and early, intensive, and repetitive rehabilitation exercises are crucial to the recovery of stroke survivors. Unfortunately, research shows that only one third of stroke patients actually perform recommended exercises at home, because of the repetitive and mundane nature of conventional rehabilitation exercises. Thus, to motivate stroke survivors to engage in monotonous rehabilitation is a significant issue in the therapy process. Game-based rehabilitation systems have the potential to encourage patients continuing rehabilitation exercises at home. However, these systems are still rarely adopted at patients' places. Discovering and eliminating the obstacles in promoting game-based rehabilitation at home is therefore essential. For this purpose, we conducted a study to collect and analyze the opinions and expectations of stroke patients and clinical therapists. The study is composed of 2 parts: Rehab-preference survey - interviews to both patients and therapists to understand the current practices, challenges, and expectations on game-based rehabilitation systems; and Rehab-compatibility survey - a gaming experiment with therapists to elaborate what commercial games are compatible with rehabilitation. The study is conducted with 30 outpatients with stroke and 19 occupational therapists from 2 rehabilitation centers in Taiwan. Our surveys show that game-based rehabilitation systems can turn the rehabilitation exercises more appealing and provide personalized motivation for various stroke patients. Patients prefer to perform rehabilitation exercises with more diverse and fun games, and need cost-effective rehabilitation systems, which are often built on commodity hardware. Our study also sheds light on incorporating the existing design-for-fun games into rehabilitation system. We envision the results are helpful in developing a platform which enables rehab-compatible (i.e., existing, appropriately selected) games to be operated on commodity hardware and brings cost-effective rehabilitation systems to more and more patients' home for long-term recovery.