Perceptions of Existing Wearable Robotic Devices for Upper Extremity and Suggestions for Their Development: Findings From Therapists and People With Stroke

Requirements for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients: a user-centred approach

PURPOSE

Telerehabilitation systems have the potential to enable therapists to monitor and assist stroke patients in achieving high-intensity upper extremity exercise in the home environment. We adopted an iterative user-centred approach, including multiple data sources and meetings with end-users and stakeholders to define the user requirements for home-based upper extremity rehabilitation using wearable motion sensors for subacute stroke patients.

METHODS

We performed a requirement analysis consisting of the following steps: 1) context & groundwork; 2) eliciting requirements; 3) modelling & analysis; 4) agreeing requirements. During these steps, a pragmatic literature search, interviews and focus groups with stroke patients, physiotherapists and occupational therapists were performed. The results were systematically analysed and prioritised into "must-haves", "should-haves", and "could-haves".

RESULTS

We formulated 33 functional requirements: eighteen must-have requirements related to blended care (2), exercise principles (7), exercise delivery (3), exercise evaluation (4), and usability (2); ten should-haves; and five could-haves. Six movement components, including twelve exercises and five combination exercises, are required. For each exercise, appropriate exercise measures were defined.

CONCLUSION

This study provides an overview of functional requirements, required exercises, and required exercise measures for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients, which can be used to develop home-based upper extremity rehabilitation interventions. Moreover, the comprehensive and systematic requirement analysis used in this study can be applied by other researchers and developers when extracting requirements for designing a system or intervention in a medical context.

Scoping Review on Brain-Computer Interface-Controlled Electrical Stimulation Interventions for Upper Limb Rehabilitation in Adults: A Look at Participants, Interventions, and Technology

Purpose

While current rehabilitation practice for improving arm and hand function relies on physical/occupational therapy, a growing body of research evaluates the effects of technology-enhanced rehabilitation. We review interventions that combine a brain-computer interface (BCI) with electrical stimulation (ES) for upper limb movement rehabilitation to summarize the evidence on (1) populations of study participants, (2) BCI-ES interventions, and (3) the BCI-ES systems.

Method

After searching seven databases, two reviewers identified 23 eligible studies. We consolidated information on the study participants, interventions, and approaches used to develop integrated BCI-ES systems. The included studies investigated the use of BCI-ES interventions with stroke and spinal cord injury (SCI) populations. All studies used electroencephalography to collect brain signals for the BCI, and functional electrical stimulation was the most common type of ES. The BCI-ES interventions were typically conducted without a therapist, with sessions varying in both frequency and duration.

Results

Of the 23 eligible studies, only 3 studies involved the SCI population, compared to 20 involving individuals with stroke.

Conclusions

Future BCI-ES interventional studies could address this gap. Additionally, standardization of device and rehabilitation modalities, and study-appropriate involvement with therapists, can be considered to advance this intervention towards clinical implementation.

Perspectives of users for a future interactive wearable system for upper extremity rehabilitation following stroke: a qualitative study

BACKGROUND

Wearable sensor technology can facilitate diagnostics and monitoring of people with upper extremity (UE) paresis after stroke. The purpose of this study is to investigate the perspectives of clinicians, people living with stroke, and their caregivers on an interactive wearable system that detects UE movements and provides feedback.

METHODS

This qualitative study used semi-structured interviews relating to the perspectives of a future interactive wearable system including a wearable sensor to capture UE movement and a user interface to provide feedback as the means of data collection. Ten rehabilitation therapists, 9 people with stroke, and 2 caregivers participated in this study.

RESULTS

Four themes were identified (1) "Everyone is different" highlighted the need for addressing individual user's rehabilitation goal and personal preference; (2) "The wearable system should identify UE and trunk movements" emphasized that in addition to arm, hand, and finger movements, detecting compensatory trunk movements during UE movements is also of interest; (3) "Both quality and amount of movements are necessary to measure" described the parameters related to how well and how much the user is using their affected UE that participants envisioned the system to monitor; (4) "Functional activities should be practiced by the users" outlined UE movements and activities that are of priority in designing the system.

CONCLUSIONS

Narratives from clinicians, people with stroke, and their caregivers offer insight into the design of interactive wearable systems. Future studies examining the experience and acceptability of existing wearable systems from end-users are warranted to guide the adoption of this technology.

Usability of a wearable device for home-based upper limb telerehabilitation in persons with stroke: A mixed-methods study

Background

The use of wearable technology offers a promising home-based self-directed option for upper limb training. Although product usability is a crucial aspect of users' acceptance of a wearable device, usability studies in wearable devices are rare, with most studies focusing primarily on clinical validity.

Objective

This study aimed to explore the usability of a wristwatch device called "Smart reminder" for home-based upper limb telerehabilitation for persons with stroke.

Methods

Eleven stroke participants used the proposed wristwatch for at least two weeks and underwent a home-based telerehabilitation program. A mixed-methods design was used to explore the usability of the wristwatch. Quantitative data were collected through the System Usability Scale (SUS) questionnaire, and the participants' rate of therapy compliance (gathered from the device) was reported descriptively. In addition, qualitative data were collected through semi-structured interviews with the participants and were analyzed using thematic analysis.

Results

The results demonstrated that the usability of the proposed wristwatch and telerehabilitation system was rated highly by the participants, with a high SUS mean score of 84.3 (12.3) and high therapy compliance rate (mean  =  91%). Qualitatively, all participants reported positive experiences with the wristwatch and indicated keenness to use it again. Participants reported physical improvements and felt motivated to exercise after using the wristwatch. They found the device easy and convenient and appreciated the remote monitoring function. Meanwhile, they highlighted critical considerations for the design of the device and program, including technical support, a wearable design of the device, graded exercise content according to ability, and flexibility in exercise schedules. Finally, they suggested that an interim review with the therapist on their progress might help them continue using the wristwatch.

Conclusions

This study's results supported the proposed wearable device's usability and showed strong acceptance by the participants for using it as a home-based upper limb telerehabilitation intervention.

Considerations for at-home upper-limb rehabilitation technology following stroke: Perspectives of stroke survivors and therapists

Introduction

This study investigated the needs of stroke survivors and therapists, and how they may contrast, for the design of robots for at-home post stroke rehabilitation therapy, in the Ontario, Canada, context.

Methods

Individual interviews were conducted with stroke survivors (n = 10) and therapists (n = 6). The transcripts were coded using thematic analysis inspired by the WHO International Classification of Functioning, Disability, and Health.

Results

Design recommendations, potential features, and barriers were identified from the interviews. Stroke survivors and therapists agreed on many of the needs for at-home robotic rehabilitation; however, stroke survivors had more insights into their home environment, barriers, and needs relating to technology, while therapists had more insights into therapy methodology and patient safety and interaction. Both groups felt a one-size-fits-all approach to rehabilitation robot design is inappropriate. Designs could address a broader range of impairments by incorporating household items and breaking activities down into their component motions. Designs should incorporate hand and wrist supports and activities. Designs should monitor trunk and shoulder motion and consider incorporating group activities.

Conclusion

While therapists can provide insight in the early stages of design of rehabilitation technology, stroke survivors' perspectives are crucial to designing for the home environment.

Design of a wearable vibrotactile stimulation device for individuals with upper-limb hemiparesis and spasticity

Vibratory stimulation may improve post-stroke symptoms such as spasticity; however, current studies are limited by the large, clinic-based apparatus used to apply this stimulation. A wearable device could provide vibratory stimulation in a mobile form, enabling further study of this technique. An initial device, the vibrotactile stimulation (VTS) Glove, was deployed in an eight-week clinical study in which sixteen individuals with stroke used the device for several hours daily. Participants reported wearing the glove during activities such as church, social events, and dining out. However, 69% of participants struggled to extend or insert their fingers to don the device. In a follow-up study, eight individuals with stroke evaluated new VTS device prototypes in a three-round iterative design study with the aims of creating the next generation of VTS devices and understanding features that influence interaction with a wearable device by individuals with impaired upper-limb function. Interviews and interaction tasks were used to define actionable design revisions between each round of evaluation. Our analysis identified six new themes from participants regarding device designs: hand supination is challenging, separate finger attachments inhibit fit and use, fingers may be flexed or open, fabric coverage impacts comfort, a reduced concern for social comfort, and the affected hand is infrequently used. Straps that wrap around the arm and fixtures on the anterior arm were other challenging features. We discuss potential accommodations for these challenges, as well as social comfort. New VTS device designs are presented and were donned in an average time of 48 seconds.

Exploring the barriers to using assistive technology for individuals with chronic conditions: a meta-synthesis review

PURPOSE

Assistive technology can provide a key tool to enabling independence, greater inclusion and participation in society for individuals with chronic conditions. This potential is currently not always realized due to barriers to accessing and using assistive technology. This review aims to identify the common barriers to acquiring and using assistive technology for users with chronic conditions through a systematic meta-synthesis. This differs from other systematic reviews by applying a transdiagnostic approach to identify if barriers are common across chronic conditions.

MATERIALS AND METHODS

A systematic literature search of five scientific databases (PubMed, SCOPUS, PsycINFO, CINAHL and Medline) was conducted to identify relevant qualitative studies. The search was conducted in November 2019. For the identified articles, thematic content analysis was conducted and the methodological quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research.

RESULTS

Forty papers met the inclusion criteria and were included in the analysis. Fifty-one descriptive themes grouped into six overarching analytical themes were identified from the studies. The analytical themes identified were: the design and function of the assistive technology, service provision, information and awareness, psychological barriers, support network and societal barriers.

CONCLUSIONS

The barriers are interconnected and common across different health conditions. More involvement in personalized care for developing strategies, adaptation of home technologies and provision of assistive technology could overcome the service provision and design barriers to assistive technology. Accessible information and providing greater awareness will be important to overcoming information, psychological and societal barriers to assistive technology.Implications for rehabilitationIndividuals with chronic conditions face complex barriers to acquiring and using assistive technology as a result of the devices themselves, their individual context, the healthcare context where assistive technology is provided and wider societal barriers.The provision of assistive technology needs to change away from the traditional medical model of the "expert" clinician and instead focus on more user involvement to deliver personalised care that utilises the users lived knowledge and experiences.Assistive technology provision should be considered alongside how to adapt everyday mainstream technology to meet user needs; the provision of devices should encourage creative problem solving rather then relying on pre-defined prescription lists of assistive technology.

Patient, carer, and staff perceptions of robotics in motor rehabilitation: a systematic review and qualitative meta-synthesis

BACKGROUND

In recent years, robotic rehabilitation devices have often been used for motor training. However, to date, no systematic reviews of qualitative studies exploring the end-user experiences of robotic devices in motor rehabilitation have been published. The aim of this study was to review end-users' (patients, carers and healthcare professionals) experiences with robotic devices in motor rehabilitation, by conducting a systematic review and thematic meta-synthesis of qualitative studies concerning the users' experiences with such robotic devices.

METHODS

Qualitative studies and mixed-methods studies with a qualitative element were eligible for inclusion. Nine electronic databases were searched from inception to August 2020, supplemented with internet searches and forward and backward citation tracking from the included studies and review articles. Data were synthesised thematically following the Thomas and Harden approach. The CASP Qualitative Checklist was used to assess the quality of the included studies of this review.

RESULTS

The search strategy identified a total of 13,556 citations and after removing duplicates and excluding citations based on title and abstract, and full text screening, 30 studies were included. All studies were considered of acceptable quality. We developed six analytical themes: logistic barriers; technological challenges; appeal and engagement; supportive interactions and relationships; benefits for physical, psychological, and social function(ing); and expanding and sustaining therapeutic options.

CONCLUSIONS

Despite experiencing technological and logistic challenges, participants found robotic devices acceptable, useful and beneficial (physically, psychologically, and socially), as well as fun and interesting. Having supportive relationships with significant others and positive therapeutic relationships with healthcare staff were considered the foundation for successful rehabilitation and recovery.

Clinicians' perceptions of a potential wearable device for capturing upper limb activity post-stroke: a qualitative focus group study

Background

There is growing interest in the use of wearable devices that track upper limb activity after stroke to help determine and motivate the optimal dose of upper limb practice. The purpose of this study was to explore clinicians’ perceptions of a prospective wearable device that captures upper limb activity to assist in the design of devices for use in rehabilitation practice.

Methods

Four focus groups with 18 clinicians (occupational and physical therapists with stroke practice experience from a hospital or private practice setting) were conducted. Data were analyzed thematically.

Results

Our analysis revealed three themes: (1) “Quantity and quality is ideal” emphasized how an ideal device would capture both quantity and quality of movement; (2) “Most useful outside therapy sessions” described how therapists foresaw using the device outside of therapy sessions to monitor homework adherence, provide self-monitoring of use, motivate greater use and provide biofeedback on movement quality; (3) “User-friendly please” advocated for the creation of a device that was easy to use and customizable, which reflected the client-centered nature of their treatment.

Conclusions

Findings from this study suggest that clinicians support the development of wearable devices that capture upper limb activity outside of therapy for individuals with some reach to grasp ability. Devices that are easy to use and capture both quality and quantity may result in greater uptake in the clinical setting. Future studies examining acceptability of wearable devices for tracking upper limb activity from the perspective of individuals with stroke are needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-021-00927-y.

Occupational therapists' evaluation of the perceived usability and utility of wearable soft robotic exoskeleton gloves for hand function rehabilitation following a stroke

PURPOSE

To evaluate the perceived usability and utility of using a soft robotic glove to rehabilitate hand function following a stroke.

METHODS

A convergent parallel mixed-methods design was used to consult a convenience sample of 14 experienced occupational therapists (OTs) practicing within a specialised stroke rehabilitation program. All OTs participated in one 60-to-90-minute individual consultation during which the attributes of a recently-developed soft robotic glove (ExoGlove) were presented before they could test it on themselves. After this consultation, OTs completed the System Usability Scale (SUS) questionnaire and answered open-ended questions focussing on the usability and utility of soft robotic gloves framed according to the Unified Theory of Acceptance and Use of Technology (UTAUT).

RESULTS

The OTs perceived the glove's usability as being moderate-to-good on the SUS (median score= 63.75 on a scale of 100). Thematic analysis revealed the importance of specifically considering elements such as ease of use (e.g. simplicity and speed), cost, movement precision, durability, and safety, when developing soft robotic gloves such as the ExoGlove.

CONCLUSIONS

Engagement in a continuous improvement process is essential to maximise the perceived usability and utility of soft robotic gloves, particularly of the ExoGlove, through their final development phase before pilot testing their effects and effectiveness for post-stroke hand rehabilitation.Implications for rehabilitationAll occupational therapists anticipate that a soft robotic glove such as the ExoGlove will allow them to increase treatment intensity and best aligns with principles of neuroplasticity.The clinical judgement and guidance of OTs, developed through practice, experience, and knowledge, remain essential to safely and efficiently exercise with a soft robotic glove.Achieving a balance between effort and performance expectancies is essential in developing and improving the functionality of soft robotic gloves, as with each additional functionality comes new challenges that impact its successful transition to a clinical setting.

Perspectives on the prospective development of stroke-specific lower extremity wearable monitoring technology: a qualitative focus group study with physical therapists and individuals with stroke

BACKGROUND

Wearable activity monitors that track step count can increase the wearer's physical activity and motivation but are infrequently designed for the slower gait speed and compensatory patterns after stroke. New and available technology may allow for the design of stroke-specific wearable monitoring devices, capable of detecting more than just step counts, which may enhance how rehabilitation is delivered. The objective of this study was to identify important considerations in the development of stroke-specific lower extremity wearable monitoring technology for rehabilitation, from the perspective of physical therapists and individuals with stroke.

METHODS

A qualitative research design with focus groups was used to collect data. Five focus groups were conducted, audio recorded, and transcribed verbatim. Data were analyzed using content analysis to generate overarching categories representing the stakeholder considerations for the development of stroke-specific wearable monitor technology for the lower extremity.

RESULTS

A total of 17 physical therapists took part in four focus group discussions and three individuals with stroke participated in the fifth focus group. Our analysis identified four main categories for consideration: 1) 'Variability' described the heterogeneity of patient presentation, therapy approaches, and therapeutic goals that are taken into account for stroke rehabilitation; 2) 'Context of use' described the different settings and purposes for which stakeholders could foresee employing stroke-specific wearable technology; 3) 'Crucial design features' identified the measures, functions, and device characteristics that should be considered for incorporation into prospective technology to enhance uptake; and 4) 'Barriers to adopting technology' highlighted challenges, including personal attitudes and design flaws, that may limit the integration of current and future wearable monitoring technology into clinical practice.

CONCLUSIONS

The findings from this qualitative study suggest that the development of stroke-specific lower extremity wearable monitoring technology is viewed positively by physical therapists and individuals with stroke. While a single, specific device or function may not accommodate all the variable needs of therapists and their clients, it was agreed that wearable monitoring technology could enhance how physical therapists assess and treat their clients. Future wearable devices should be developed in consideration of the highlighted design features and potential barriers for uptake.

Evaluation of a Novel Wellness Assessment Device (Preventiometer): A Feasibility Pilot Study

Background

Periodic wellness assessments can provide an estimate of a person’s relative risks for major diseases, but wellness visits are underused. Our suggestion is to use a comprehensive device during a single visit.

Objective

The goal of this pilot study was to evaluate the feasibility of a novel one-stop wellness device (Preventiometer; iPEx5 GmbH, Greifswald, Germany) for performing multiple tests and providing a comprehensive wellness assessment in a short period.

Methods

A Preventiometer was used to provide wellness assessments for 10 healthy volunteers who then answered a 25-question survey to rate their satisfaction with the testing and their overall impression.

Results

All volunteers agreed or strongly agreed with the following: The assessment reports were easy to understand, the Preventiometer met their satisfaction, the participants were comfortable during the assessment, and all measurements and testing were well coordinated. Participants liked the instant test result feature. Most (90%) agreed that the machine was useful for a quick health assessment for busy people, and 70% felt that it was time efficient.

Conclusion

In this feasibility pilot study, the Preventiometer performed multiple tasks and provided a comprehensive wellness assessment in a short period. Participants reported remarkably high satisfaction with the tests. A larger study is needed to prove that this is a pragmatic approach to help individuals improve their health.