A review of the evidence underpinning the use of visual and auditory feedback for computer technology in post-stroke upper-limb rehabilitation

Critical quality appraisal and algorithm development of clinical practice guidelines for management of poststroke sensory loss: a systematic review

OBJECTIVES

This study aimed to assess the methodological quality of clinical practice guidelines (CPGs) associated with the management of poststroke sensory loss and develop an algorithm for health professionals.

METHODS

We conducted a systematic review for relevant CPGs published between 2017 and 2022 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist. Appraisal of Guidelines for Research and Evaluation II instrument was used to assess methodological quality. Recommendations for managing poststroke sensory loss from high and average-quality CPGs were summarised and developed into an algorithm.

RESULTS

First, 1458 records were identified from the database searches and other sources. Finally, four CPGs were included: three were rated as high quality and one as average quality. Twenty-two recommendations were summarised from these CPGs and used to develop a draft algorithm. Then, we revised the draft algorithm developed by the authors based on expert feedback to form the final version.

CONCLUSIONS

The four CPGs included in this study had good quality. Based on these CPGs, we developed an algorithm to facilitate health professionals' adherence to CPGs and contribute to evidence-based medicine. In the future, more high-quality CPGs are required to give further scientific and convincing evidence to manage poststroke sensory loss.

A data set for the design and implementation of the upper limb disability registry

BACKGROUND

If the data elements needed for patient registries are not identified, designing and implementing them can be very challenging. Identifying and introducing a Data Set (DS) can help solve this challenge. The aim of this study was to identify and present a DS for the design and implementation of the upper limb disability registry.

MATERIALS AND METHODS

This cross-sectional study was conducted in two phases. In the first phase, to identify the administrative and clinical data elements required for registry, a comprehensive study was conducted in PubMed, Web of Science, and Scopus databases. Then, the necessary data elements were extracted from the studies and a questionnaire was designed based on them. In the second phase, in order to confirm the DS, the questionnaire was distributed to 20 orthopedic, physical medicine and rehabilitation physicians and physiotherapists during a two-round Delphi. In order to analyze the data, the frequency and mean score of each data element were calculated. Data elements that received an agreement more than 75% in the first or two-round Delphi were considered for the final DS.

RESULTS

A total of 81 data elements in five categories of "demographic data", "clinical presentation", "past medical history", "psychological issues", and "pharmacological and non-pharmacological treatments" were extracted from the studies. Finally, 78 data elements were approved by experts as essential data elements for designing a patient registry for upper limb disabilities.

CONCLUSION

In this study, the data elements necessary for the design and implementation of the upper limb disability registry were suggested. This DS can help registry designers and health data administrators know what data needs to be included in the registry system in order to have a successful design and implementation. Moreover, this standardized DS can be effective for integrating and improving the information management of people with upper limb disabilities and used to accurately gather the upper limb disabilities data for research and policymaking purposes.

Automating provision of feedback to stroke patients with and without information on compensatory movements: A pilot study

Providing effective feedback to patients in a rehabilitation training program is essential. As technologies are being developed to support patient training, they need to be able to provide the users with feedback on their performance. As there are various aspects on which feedback can be given (e.g., task success and presence of compensatory movements), it is important to ensure that users are not overwhelmed by too much information given too frequently by the assistive technology. We created a rule-based set of guidelines for the desired hierarchy, timing, and content of feedback to be used when stroke patients train with an upper-limb exercise platform which we developed. The feedback applies to both success on task completion and to the execution of compensatory movements, and is based on input collected from clinicians in a previous study. We recruited 11 stroke patients 1–72 months from injury onset. Ten participants completed the training; each trained with the rehabilitation platform in two configurations: with motor feedback (MF) and with no motor feedback (control condition) (CT). The two conditions were identical, except for the feedback content provided: in both conditions they received feedback on task success; in the MF condition they also received feedback on making undesired compensatory movements during the task. Participants preferred the configuration that provided feedback on both task success and quality of movement (MF). This pilot experiment demonstrates the feasibility of a system providing both task-success and movement-quality feedback to patients based on a decision tree which we developed.

Brazilian practice guidelines for stroke rehabilitation: Part II

The Brazilian Practice Guidelines for Stroke Rehabilitation - Part II, developed by the Scientific Department of Neurological Rehabilitation of the Brazilian Academy of Neurology (Academia Brasileira de Neurologia, in Portuguese), focuses on specific rehabilitation techniques to aid recovery from impairment and disability after stroke. As in Part I, Part II is also based on recently available evidence from randomized controlled trials, systematic reviews, meta-analyses, and other guidelines. Part II covers disorders of communication, dysphagia, postural control and balance, ataxias, spasticity, upper limb rehabilitation, gait, cognition, unilateral spatial neglect, sensory impairments, home rehabilitation, medication adherence, palliative care, cerebrovascular events related to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, the future of stroke rehabilitation, and stroke websites to support patients and caregivers. Our goal is to provide health professionals with more recent knowledge and recommendations for better rehabilitation care after stroke.

The Short-Term Effects of Rhythmic Vibrotactile and Auditory Biofeedback on the Gait of Individuals After Weight-Induced Asymmetry

BACKGROUND

Biofeedback (BFB), the practice of providing real-time sensory feedback has been shown to improve gait rehabilitation outcomes. BFB training through rhythmic stimulation has the potential to improve spatiotemporal gait asymmetries while minimizing cognitive load by encouraging a synchronization between the user's gait cycle and an external rhythm.

OBJECTIVE

The purpose of this work was to evaluate if rhythmic stimulation can improve the stance time symmetry ratio (STSR) and to compare vibrotactile to auditory stimulation. Gait parameters including velocity, cadence, stride length, double support time, and step length symmetry, were also examined.

METHODOLOGY

An experimental rhythmic stimulation system was developed, and twelve healthy adults (5 males), age 28.42 ± 10.93 years, were recruited to participate in walking trials. A unilateral ankle weight was used to induce a gait asymmetry to simulate asymmetry as commonly exhibited by individuals with lower limb amputation and other clinical disorders. Four conditions were evaluated: 1) No ankle weight baseline, 2) ankle weight without rhythmic stimulation, 3) ankle weight + rhythmic vibrotactile stimulation (RVS) using alternating motors and 4) ankle weight + rhythmic auditory stimulation (RAS) using a singletone metronome at the participant's self-selected cadence.

FINDINGS

As expected the STSR became significantly more asymmetrical with the ankle weight (i.e. induced asymmetry condition). STSR improved significantly with RVS and RAS when compared to the ankle weight without rhythmic stimulation. Cadence also significantly improved with RVS and RAS compared to ankle weight without rhythmic stimulation. With the exception of double support time, the other gait parameters were unchanged from the ankle weight condition. There were no statistically significant differences between RVS and RAS.

CONCLUSION

This study found that rhythmic stimulation can improve the STSR when an asymmetry is induced. Moreover, RVS is at least as effective as auditory stimulation in improving STSR in healthy adults with an induced gait asymmetry. Future work should be extended to populations with mobility impairments and outside of laboratory settings.

Adaptability of Assistive Mobility Devices and the Role of the Internet of Medical Things: Comprehensive Review

Background

With the projected upsurge in the percentage of people with some form of disability, there has been a significant increase in the need for assistive mobility devices. However, for mobility aids to be effective, such devices should be adapted to the user’s needs. This can be achieved by improving the confidence of the acquired information (interaction between the user, the environment, and the device) following design specifications. Therefore, there is a need for literature review on the adaptability of assistive mobility devices.

Objective

In this study, we aim to review the adaptability of assistive mobility devices and the role of the internet of medical things in terms of the acquired information for assistive mobility devices. We review internet-enabled assistive mobility technologies and non–internet of things (IoT) assistive mobility devices. These technologies will provide awareness of the status of adaptive mobility technology and serve as a source and reference regarding information to health care professionals and researchers.

Methods

We performed a literature review search on the following databases of academic references and journals: Google Scholar, ScienceDirect, Institute of Electrical and Electronics Engineers, Springer, and websites of assistive mobility and foundations presenting studies on assistive mobility found through a generic Google search (including the World Health Organization website). The following keywords were used: assistive mobility OR assistive robots, assistive mobility devices, internet-enabled assistive mobility technologies, IoT Framework OR IoT Architecture AND for Healthcare, assisted navigation OR autonomous navigation, mobility AND aids OR devices, adaptability of assistive technology, adaptive mobility devices, pattern recognition, autonomous navigational systems, human-robot interfaces, motor rehabilitation devices, perception, and ambient assisted living.

Results

We identified 13,286 results (excluding titles that were not relevant to this study). Then, through a narrative review, we selected 189 potential studies (189/13,286, 1.42%) from the existing literature on the adaptability of assistive mobility devices and IoT frameworks for assistive mobility and conducted a critical analysis. Of the 189 potential studies, 82 (43.4%) were selected for analysis after meeting the inclusion criteria. On the basis of the type of technologies presented in the reviewed articles, we proposed a categorization of the adaptability of smart assistive mobility devices in terms of their interaction with the user (user system interface), perception techniques, and communication and sensing frameworks.

Conclusions

We discussed notable limitations of the reviewed literature studies. The findings revealed that an improvement in the adaptation of assistive mobility systems would require a reduction in training time and avoidance of cognitive overload. Furthermore, sensor fusion and classification accuracy are critical for achieving real-world testing requirements. Finally, the trade-off between cost and performance should be considered in the commercialization of these devices.

Versatile GCH Control Software for Correction of Loads Applied to Forearm Crutches During Gait Recovery Through Technological Feedback: Development and Implementation Study

Background

Measuring weight bearing is an essential aspect of clinical care for lower limb injuries such as sprains or meniscopathy surgeries. This care often involves the use of forearm crutches for partial loads progressing to full loads. Therefore, feasible methods of load monitoring for daily clinical use are needed.

Objective

The main objective of this study was to design an innovative multifunctional desktop load-measuring software that complements GCH System 2.0–instrumented forearm crutches and monitors the applied loads, displaying real-time graphical and numerical information, and enabling the correction of inaccuracies through feedback technology during assisted gait. The secondary objective was to perform a preliminary implementation trial.

Methods

The software was designed for indoor use (clinics/laboratories). This software translates the crutch sensor signal in millivolts into force units, records and analyzes data (10-80 Hz), and provides real-time effective curves of the loads exerted on crutches. It covers numerous types of extrinsic feedback, including visual, acoustic (verbal/beeps), concurrent, terminal, and descriptive feedback, and includes a clinical and research use database. An observational descriptive pilot study was performed with 10 healthy subjects experienced in bilateral assisted gait. The Wilcoxon matched-pairs signed-rank test was used to evaluate the load accuracy evolution of each subject (ie, changes in the loads exerted on crutches for each support) among various walks, which was interpreted at the 95% confidence level.

Results

GCH Control Software was developed as a multifunctional desktop tool complementing GCH System 2.0–instrumented forearm crutches. The pilot implementation of the feedback mechanism observed 96/100 load errors at baseline (walk 0, no feedback) with 7/10 subjects exhibiting crutch overloading. Errors ranged from 61.09% to 203.98%, demonstrating heterogeneity. The double-bar feedback found 54/100 errors in walk 1, 28/100 in walk 2, and 14/100 in walk 3. The first walk with double-bar feedback (walk 1) began with errors similar to the baseline walk, generally followed by attempts at correction. The Wilcoxon matched-pairs signed-rank test used to evaluate each subject’s progress showed that all participants steadily improved the accuracy of the loads applied to the crutches. In particular, Subject 9 required extra feedback with two single-bar walks to focus on the total load. The participants also corrected the load balance between crutches and fluency errors. Three subjects made one error of load balance and one subject made six fluctuation errors during the three double-bar walks. The latter subject performed additional feedback with two balance-bar walks to focus on the load balance.

Conclusions

GCH Control Software proved to be useful for monitoring the loads exerted on forearm crutches, providing a variety of feedback for correcting load accuracy, load balance between crutches, and fluency. The findings of the complementary implementation were satisfactory, although clinical trials with larger samples are needed to assess the efficacy of the different feedback mechanisms and to select the best alternatives in each case.

Load Auditory Feedback Boosts Crutch Usage in Subjects With Central Nervous System Lesions: A Pilot Study

Background: Crutches are the most common walking aids prescribed to improve mobility in subjects with central nervous system (CNS) lesions. To increase adherence to the appropriate level of crutch usage, providing load-related auditory feedback (aFB) may be a useful approach. We sensorized forearm crutches and developed a custom software to provide aFB information to both user and physical therapist (PhT).

Aim: Evaluate aFB effects on load control during gait by a self-controlled case series trial.

Methods: A single experimental session was conducted enrolling 12 CNS lesioned participants. Load on crutch was recorded during 10 Meter Walk Test performed with and without aFB. In both cases, crutch load data, and gait speed were recorded. Usability and satisfaction questionnaires were administered to participants and PhTs involved.

Results: Reliable data were obtained from eight participants. Results showed that compared to the no FB condition, aFB yielded a significant reduction in the mean load on the crutches during gait (p = 0.001). The FB did not influence gait speed or fatigue (p > 0.05). The experience questionnaire data indicated a positive experience regarding the use of aFB from both participants' and PhTs' perspectives.

Conclusion: aFB significantly improves compliance with crutch use and does not affect gait speed or fatigue by improving the load placed on crutches. The FB is perceived by users as helpful, safe, and easy to learn, and does not interfere with attention or concentration while walking. Furthermore, the PhTs consider the system to be useful, easy to learn and reliable.

Factors Associated With Adherence to Self-Managed Aphasia Therapy Practice on a Computer-A Mixed Methods Study Alongside a Randomized Controlled Trial

Background: Aphasia is a communication disorder often acquired after a stroke. Independent use of specialist aphasia software on a home computer is a form of asynchronous tele-rehabilitation that can provide increased opportunity for practice of rehabilitation exercises. This study aimed to explore the factors associated with adherence to self-managed aphasia computer therapy practice.

Method: A mixed methods exploration of adherence was conducted alongside the Big CACTUS randomized controlled trial [ISRCTN: 68798818]. The trial evaluated the clinical effectiveness of self-managed aphasia computer therapy. This study reports secondary analysis of data from participants randomized to the computer therapy group to investigate whether any demographic, clinical or intervention variables were associated with adherence to therapy practice. A sub-sample of the same participants took part in qualitative interviews exploring the factors perceived to influence the amount of aphasia computer therapy practice undertaken. Interviews were analyzed thematically. A convergence-coding matrix was used to triangulate the two sets of findings.

Results: Data from 85 participants randomized to the computer therapy group were included in the quantitative analyses. At a clinical level, a greater length of time post-stroke was associated with higher adherence to self-managed aphasia therapy practice on a computer. At an intervention level, length of computer therapy access and therapist time supporting the participant were associated with greater adherence to computer therapy practice. Interviews with 11 patients and 12 informal carers identified a multitude of factors perceived to influence engagement with tele-rehabilitation by people with aphasia. The factors grouped around three themes: capability to use the computer therapy, having the opportunity to practice (external influences and technological issues) and motivation (beliefs, goals and intentions vs. personality, emotions, habit and reinforcement). Triangulation demonstrated convergence for the finding that participants' practiced computer-based therapy exercises more when they received increased support from a speech and language therapist.

Conclusion: Clinicians delivering asynchronous tele-rehabilitation involving self-management of aphasia therapy practice on a computer should consider the factors found to be associated with engagement when deciding which patients may be suited to this option, as well as how they can be supported to optimize the amount of practice they engage in.

Wearable Wrist Movement Monitoring Using Dual Surface-Treated Plastic Optical Fibers

Regarding high-sensitivity human wrist joint motion monitoring in exercise rehabilitation; we develop a pair of novel wearable and sensitivity-enhanced plastic optical fiber (POF) strain sensors consisting of an etched grating fiber and a side-polished fiber stitched into a polyamide wrist brace. The two flexible and surface-treated fibers are; respectively; featured with an etched periodic gratings with a pitch of 6 mm and a depth of 0.5 mm and a D-shaped side-polished zone of ~300 µm depth and ~30 mm length; which, correspondingly, show the sensitivities of around 0.0176/° and 0.0167/° in a normalized bending angle by far larger than a conventional commercial POF, because it achieves a more sensitive strain-induced evanescent field interaction with the side-machined fibers. Moreover, in terms of the sensor response to bending deformation in the range of -40°~+40°, the former exhibits a better sensitivity in lower angle change, while the latter is superior as the bending angle increases; thereby arranging the two modified POFs separately at the side and back of the human wrist, in order to decouple the wrist joint behaviors induced by typical flexion-extension or abduction-adduction movements. Then, the circular and pentagonal wrist motion trajectory patterns are investigated, to demonstrate the maximum average single-axis motion error of 2.94° via the transformation of spatial angle to plane coordinate for the fabricated couple of POF sensors, which is lower than a recognized standard of 5°, thus suggesting the great potential in wearable exercise rehabilitation of human joints in the field of medical treatment and healing.

Effectiveness of Upper Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: Systematic Review

BACKGROUND

With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Upper limb (UL) impairment affects up to 77% of stroke survivors impacting on their ability to carry out everyday activities. However, despite an increase in research exploring these devices for UL rehabilitation, little is known of their effectiveness.

OBJECTIVE

This review aimed to assess the effectiveness of UL wearable technology for improving activity and participation in adult stroke survivors.

METHODS

Randomized controlled trials (RCTs) and randomized comparable trials of UL wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability, and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs and the Downs and Black Instrument for the quality of non RCTs.

RESULTS

In the review, we included 11 studies with collectively 354 participants at baseline and 323 participants at final follow-up including control groups and participants poststroke. Participants' stroke type and severity varied. Only 1 study found significant between-group differences for systems functioning and activity (P≤.02). The 11 included studies in this review had small sample sizes ranging from 5 to 99 participants at an average (mean) age of 57 years.

CONCLUSIONS

This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes and the appropriateness of the methodology for complex interventions. However, technology has the potential to measure outcomes, provide feedback, and engage users outside of clinical sessions. This could provide a platform for motivating stroke survivors to carry out more rehabilitation in the absence of a therapist, which could maximize recovery.

TRIAL REGISTRATION

PROSPERO CRD42017057715; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=57715.

Feedback Design in Targeted Exercise Digital Biofeedback Systems for Home Rehabilitation: A Scoping Review

Digital biofeedback systems (DBSs) are used in physical rehabilitation to improve outcomes by engaging and educating patients and have the potential to support patients while doing targeted exercises during home rehabilitation. The components of feedback (mode, content, frequency and timing) can influence motor learning and engagement in various ways. The feedback design used in DBSs for targeted exercise home rehabilitation, as well as the evidence underpinning the feedback and how it is evaluated, is not clearly known. To explore these concepts, we conducted a scoping review where an electronic search of PUBMED, PEDro and ACM digital libraries was conducted from January 2000 to July 2019. The main inclusion criteria included DBSs for targeted exercises, in a home rehabilitation setting, which have been tested on a clinical population. Nineteen papers were reviewed, detailing thirteen different DBSs. Feedback was mainly visual, concurrent and descriptive, frequently providing knowledge of results. Three systems provided clear rationale for the use of feedback. Four studies conducted specific evaluations of the feedback, and seven studies evaluated feedback in a less detailed or indirect manner. Future studies should describe in detail the feedback design in DBSs and consider a robust evaluation of the feedback element of the intervention to determine its efficacy.

Technology-Based Feedback and Its Efficacy in Improving Gait Parameters in Patients with Abnormal Gait: A Systematic Review

This systematic review synthesized and analyzed clinical findings related to the effectiveness of innovative technological feedback for tackling functional gait recovery. An electronic search of PUBMED, PEDro, WOS, CINAHL, and DIALNET was conducted from January 2011 to December 2016. The main inclusion criteria were: patients with modified or abnormal gait; application of technology-based feedback to deal with functional recovery of gait; any comparison between different kinds of feedback applied by means of technology, or any comparison between technological and non-technological feedback; and randomized controlled trials. Twenty papers were included. The populations were neurological patients (75%), orthopedic and healthy subjects. All participants were adults, bar one. Four studies used exoskeletons, 6 load platforms and 5 pressure sensors. The breakdown of the type of feedback used was as follows: 60% visual, 40% acoustic and 15% haptic. 55% used terminal feedback versus 65% simultaneous feedback. Prescriptive feedback was used in 60% of cases, while 50% used descriptive feedback. 62.5% and 58.33% of the trials showed a significant effect in improving step length and speed, respectively. Efficacy in improving other gait parameters such as balance or range of movement is observed in more than 75% of the studies with significant outcomes.

CONCLUSION

Treatments based on feedback using innovative technology in patients with abnormal gait are mostly effective in improving gait parameters and therefore useful for the functional recovery of patients. The most frequently highlighted types of feedback were immediate visual feedback followed by terminal and immediate acoustic feedback.

A Community-Based, Bionic Leg Rehabilitation Program for Patients with Chronic Stroke: Clinical Trial Protocol

Stroke is a major global health problem whereby many survivors have unmet needs concerning mobility during recovery. As such, the use of robotic-assisted devices (i.e., a bionic leg) within a community setting may be an important adjunct to normal physiotherapy in chronic stroke survivors. This study will be a dual-center, randomized, parallel group clinical trial to investigate the impact of a community-based training program using a bionic leg on biomechanical, cardiovascular, and functional outcomes in stroke survivors. Following a baseline assessment that will assess gait, postural sway, vascular health (blood pressure, arterial stiffness), and functional outcomes (6-minute walk), participants will be randomized to a 10-week program group, incorporating (1) a physiotherapy plus community-based bionic leg training program; (2) physiotherapy only; or (3) usual care control. The training program will involve participants engaging in a minimum of 1 hour per day of bionic leg activities at home. Follow-up assessments, identical to baseline, will occur after 10 weeks, and 3 and 12 months postintervention. Given the practical implications of the study, the clinical significance of using the bionic leg will be assessed for each outcome variable. The potential improvements in gait, balance, vascular health, and functional status may have a meaningful impact on patients' quality of life. The integration of robotic devices within home-based rehabilitation programs may prove to be a cost-effective, practical, and beneficial resource for stroke survivors.

Constraints and Adaptation of Closed-Loop Neuroprosthetics for Functional Restoration

Closed-loop neuroprosthetics aim to compensate for lost function, e.g., by controlling external devices such as prostheses or wheelchairs. Such assistive approaches seek to maximize speed and classification accuracy for high-dimensional control. More recent approaches use similar technology, but aim to restore lost motor function in the long term. To achieve this goal, restorative neuroprosthetics attempt to facilitate motor re-learning and to strengthen damaged and/or alternative neural connections on the basis of neurofeedback training within rehabilitative environments. Such a restorative approach requires reinforcement learning of self-modulated brain activity which is considered to be beneficial for functional rehabilitation, e.g., improvement of β-power modulation over sensorimotor areas for post-stroke movement restoration. Patients with motor impairments, however, may also have a compromised ability for motor task-related regulation of the targeted brain activity. This would affect the estimation of feature weights and hence the classification accuracy of the feedback device. This, in turn, can frustrate the patients and compromise their motor learning. Furthermore, the feedback training may even become erroneous when unconstrained classifier adaptation-which is often used in assistive approaches-is also applied in this rehabilitation context. In conclusion, the conceptual switch from assistance toward restoration necessitates a methodological paradigm shift from classification accuracy toward instructional efficiency. Furthermore, a constrained feature space, a priori regularized feature weights, and difficulty adaptation present key elements of restorative brain interfaces. These factors need, therefore, to be addressed within a therapeutic framework to facilitate reinforcement learning of brain self-regulation for restorative purposes.

A Personalized Self-Management Rehabilitation System for Stroke Survivors: A Quantitative Gait Analysis Using a Smart Insole

BACKGROUND

In the United Kingdom, stroke is the single largest cause of adult disability and results in a cost to the economy of £8.9 billion per annum. Service needs are currently not being met; therefore, initiatives that focus on patient-centered care that promote long-term self-management for chronic conditions should be at the forefront of service redesign. The use of innovative technologies and the ability to apply these effectively to promote behavior change are paramount in meeting the current challenges.

OBJECTIVE

Our objective was to gain a deeper insight into the impact of innovative technologies in support of home-based, self-managed rehabilitation for stroke survivors. An intervention of daily walks can assist with improving lower limb motor function, and this can be measured by using technology. This paper focuses on assessing the usage of self-management technologies on poststroke survivors while undergoing rehabilitation at home.

METHODS

A realist evaluation of a personalized self-management rehabilitation system was undertaken in the homes of stroke survivors (N=5) over a period of approximately two months. Context, mechanisms, and outcomes were developed and explored using theories relating to motor recovery. Participants were encouraged to self-manage their daily walking activity; this was achieved through goal setting and motivational feedback. Gait data were collected and analyzed to produce metrics such as speed, heel strikes, and symmetry. This was achieved using a "smart insole" to facilitate measurement of walking activities in a free-living, nonrestrictive environment.

RESULTS

Initial findings indicated that 4 out of 5 participants performed better during the second half of the evaluation. Performance increase was evident through improved heel strikes on participants' affected limb. Additionally, increase in performance in relation to speed was also evident for all 5 participants. A common strategy emerged across all but one participant as symmetry performance was sacrificed in favor of improved heel strikes. This paper evaluates compliance and intensity of use.

CONCLUSION

Our findings suggested that 4 out of the 5 participants improved their ability to heel strike on their affected limb. All participants showed improvements in their speed of gait measured in steps per minute with an average increase of 9.8% during the rehabilitation program. Performance in relation to symmetry showed an 8.5% average decline across participants, although 1 participant improved by 4%. Context, mechanism, and outcomes indicated that dual motor learning and compensatory strategies were deployed by the participants.

The Effectiveness of Lower-Limb Wearable Technology for Improving Activity and Participation in Adult Stroke Survivors: A Systematic Review

Background

With advances in technology, the adoption of wearable devices has become a viable adjunct in poststroke rehabilitation. Regaining ambulation is a top priority for an increasing number of stroke survivors. However, despite an increase in research exploring these devices for lower limb rehabilitation, little is known of the effectiveness.

Objective

This review aims to assess the effectiveness of lower limb wearable technology for improving activity and participation in adult stroke survivors.

Methods

Randomized controlled trials (RCTs) of lower limb wearable technology for poststroke rehabilitation were included. Primary outcome measures were validated measures of activity and participation as defined by the International Classification of Functioning, Disability and Health. Databases searched were MEDLINE, Web of Science (Core collection), CINAHL, and the Cochrane Library. The Cochrane Risk of Bias Tool was used to assess the methodological quality of the RCTs.

Results

In the review, we included 11 RCTs with collectively 550 participants at baseline and 474 participants at final follow-up including control groups and participants post stroke. Participants' stroke type and severity varied. Only one study found significant between-group differences for systems functioning and activity. Across the included RCTs, the lowest number of participants was 12 and the highest was 151 with a mean of 49 participants. The lowest number of participants to drop out of an RCT was zero in two of the studies and 19 in one study. Significant between-group differences were found across three of the 11 included trials. Out of the activity and participation measures alone, P values ranged from P=.87 to P ≤.001.

Conclusions

This review has highlighted a number of reasons for insignificant findings in this area including low sample sizes, appropriateness of the RCT methodology for complex interventions, a lack of appropriate analysis of outcome data, and participant stroke severity.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Reinforcement learning for adaptive threshold control of restorative brain-computer interfaces: a Bayesian simulation

Restorative brain-computer interfaces (BCI) are increasingly used to provide feedback of neuronal states in a bid to normalize pathological brain activity and achieve behavioral gains. However, patients and healthy subjects alike often show a large variability, or even inability, of brain self-regulation for BCI control, known as BCI illiteracy. Although current co-adaptive algorithms are powerful for assistive BCIs, their inherent class switching clashes with the operant conditioning goal of restorative BCIs. Moreover, due to the treatment rationale, the classifier of restorative BCIs usually has a constrained feature space, thus limiting the possibility of classifier adaptation. In this context, we applied a Bayesian model of neurofeedback and reinforcement learning for different threshold selection strategies to study the impact of threshold adaptation of a linear classifier on optimizing restorative BCIs. For each feedback iteration, we first determined the thresholds that result in minimal action entropy and maximal instructional efficiency. We then used the resulting vector for the simulation of continuous threshold adaptation. We could thus show that threshold adaptation can improve reinforcement learning, particularly in cases of BCI illiteracy. Finally, on the basis of information-theory, we provided an explanation for the achieved benefits of adaptive threshold setting.

Development and preliminary evaluation of a novel low cost VR-based upper limb stroke rehabilitation platform using Wii technology

PURPOSE

This paper proposes a novel system (using the Nintendo Wii remote) that offers customised, non-immersive, virtual reality-based, upper-limb stroke rehabilitation and reports on promising preliminary findings with stroke survivors.

METHOD

The system novelty lies in the high accuracy of the full kinematic tracking of the upper limb movement in real-time, offering strong personal connection between the stroke survivor and a virtual character when executing therapist prescribed adjustable exercises/games. It allows the therapist to monitor patient performance and to individually calibrate the system in terms of range of movement, speed and duration.

RESULTS

The system was tested for acceptability with three stroke survivors with differing levels of disability. Participants reported an overwhelming connection with the system and avatar. A two-week, single case study with a long-term stroke survivor showed positive changes in all four outcome measures employed, with the participant reporting better wrist control and greater functional use. Activities, which were deemed too challenging or too easy were associated with lower scores of enjoyment/motivation, highlighting the need for activities to be individually calibrated.

CONCLUSIONS

Given the preliminary findings, it would be beneficial to extend the case study in terms of duration and participants and to conduct an acceptability and feasibility study with community dwelling survivors. Implications for Rehabilitation Low-cost, off-the-shelf game sensors, such as the Nintendo Wii remote, are acceptable by stroke survivors as an add-on to upper limb stroke rehabilitation but have to be bespoked to provide high-fidelity and real-time kinematic tracking of the arm movement. Providing therapists with real-time and remote monitoring of the quality of the movement and not just the amount of practice, is imperative and most critical for getting a better understanding of each patient and administering the right amount and type of exercise. The ability to translate therapeutic arm movement into individually calibrated exercises and games, allows accommodation of the wide range of movement difficulties seen after stroke and the ability to adjust these activities (in terms of speed, range of movement and duration) will aid motivation and adherence - key issues in rehabilitation. With increasing pressures on resources and the move to more community-based rehabilitation, the proposed system has the potential for promoting the intensity of practice necessary for recovery in both community and acute settings.

Stroke patients' utilisation of extrinsic feedback from computer-based technology in the home: a multiple case study realistic evaluation

Background

Evidence indicates that post − stroke rehabilitation improves function, independence and quality of life. A key aspect of rehabilitation is the provision of appropriate information and feedback to the learner.

Advances in information and communications technology (ICT) have allowed for the development of various systems to complement stroke rehabilitation that could be used in the home setting. These systems may increase the provision of rehabilitation a stroke survivor receives and carries out, as well as providing a learning platform that facilitates long-term self-managed rehabilitation and behaviour change. This paper describes the application of an innovative evaluative methodology to explore the utilisation of feedback for post-stroke upper-limb rehabilitation in the home.

Methods

Using the principles of realistic evaluation, this study aimed to test and refine intervention theories by exploring the complex interactions of contexts, mechanisms and outcomes that arise from technology deployment in the home. Methods included focus groups followed by multi-method case studies (n = 5) before, during and after the use of computer-based equipment. Data were analysed in relation to the context-mechanism-outcome hypotheses case by case. This was followed by a synthesis of the findings to answer the question, ‘what works for whom and in what circumstances and respects?’

Results

Data analysis reveals that to achieve desired outcomes through the use of ICT, key elements of computer feedback, such as accuracy, measurability, rewarding feedback, adaptability, and knowledge of results feedback, are required to trigger the theory-driven mechanisms underpinning the intervention. In addition, the pre-existing context and the personal and environmental contexts, such as previous experience of service delivery, personal goals, trust in the technology, and social circumstances may also enable or constrain the underpinning theory-driven mechanisms.

Conclusions

Findings suggest that the theory-driven mechanisms underpinning the utilisation of feedback from computer-based technology for home-based upper-limb post-stroke rehabilitation are dependent on key elements of computer feedback and the personal and environmental context. The identification of these elements may therefore inform the development of technology; therapy education and the subsequent adoption of technology and a self-management paradigm; long-term self-managed rehabilitation; and importantly, improvements in the physical and psychosocial aspects of recovery.

Feedback-mediated upper extremities exercise: increasing patient motivation in poststroke rehabilitation

PURPOSE

This proof-of-concept study investigated whether feedback-mediated exercise (FME) of the affected arm of hemiplegic patients increases patient motivation and promotes greater improvement of motor function, compared to no-feedback exercise (NFE).

METHOD

We developed a feedback-mediated treatment that uses gaming scenarios and allows online and offline monitoring of both temporal and spatial characteristics of planar movements. Twenty poststroke hemiplegic inpatients, randomly assigned to the FME and NFE group, received therapy five days a week for three weeks. The outcome measures were evaluated from the following: (1) the modified drawing test (mDT), (2) received therapy time-RTT, and (3) intrinsic motivation inventory-IMI.

RESULTS

The FME group patients showed significantly higher improvement in the speed metric (P < 0.01), and smoothness metric (P < 0.01), as well as higher RTT (P < 0.01). Significantly higher patient motivation is observed in the FME group (interest/enjoyment subscale (P < 0.01) and perceived competence subscale (P < 0.01)).

CONCLUSION

Prolonged endurance in training and greater improvement in certain areas of motor function, as well as very high patient motivation and strong positive impressions about the treatment, suggest the positive effects of feedback-mediated treatment and its high level of acceptance by patients.

The provision of feedback through computer-based technology to promote self-managed post-stroke rehabilitation in the home

PURPOSE

Building on previous research findings, this article describes the development of the feedback interfaces for a Personalised Self-Managed Rehabilitation System (PSMrS) for home-based post-stroke rehabilitation using computer-based technology.

METHOD

Embedded within a realistic evaluative methodological approach, the development of the feedback interfaces for the PSMrS involved the incorporation of existing and emerging theories and a hybrid of health and social sciences research and user-centred design methods.

RESULTS

User testing confirmed that extrinsic feedback for home-based post-stroke rehabilitation through computer-based technology needs to be personalisable, accurate, rewarding and measurable. In addition, user testing also confirmed the feasibility of using specific components of the PSMrS.

CONCLUSIONS

A number of key elements are crucial for the development and potential utilisation of technology in what is an inevitable shift towards the use of innovative methods of delivering post-stroke rehabilitation. This includes the specific elements that are essential for the promotion of self-managed rehabilitation and rehabilitative behaviour change; the impact of the context on the mechanisms; and, importantly, the need for reliability and accuracy of the technology.

Improving fine motor function after brain injury using gesture recognition biofeedback

PURPOSE

We developed a gesture recognition biofeedback (GRB) device for improving fine motor function in persons with brain injury using surface muscle pressures of the forearm to provide real-time visual biofeedback. The GRB apparatus is easy to don by moderately impaired users and does not require precise placement of sensors.

METHOD

The efficacy of GRB training with each subject was assessed by comparing its effectiveness against standard repetitive training without feedback. The outcome was measured using a nine-hole peg test (HPT) administered before and after each condition, in a cross-over study design.

RESULTS

GRB was shown to be effective for short-term improvement of fine motor function of 12 impaired participants, reducing their average time to completion of the HPT by 15.5% (S.D. 7.14%). In a subset of impaired subjects, this effect was significant in comparison to similar training without biofeedback (p < 0.05). Control subjects experienced negligible change in HPT time.

CONCLUSIONS

This pilot study of a heterogeneous group shows that GRB may offer a simple means to help impaired users re-learn specified manual tasks.