Computer-based assistive technology and changes in daily living after stroke

Acceptability of two mobile applications to support cross-sectoral, person-centred and empowering stroke rehabilitation - a process evaluation

AIM

To evaluate the acceptability of two co-designed mobile applications Mit Sygehus [a knowledge-based solution] and Genoptræn.dk [a self-training solution] to support a cross-sectoral, person-centred and empowering stroke rehabilitation.

SETTING

The applications were implemented and tested throughout two stroke rehabilitation trajectories in Southern Denmark, comprising two acute, two sub-acute and two municipal stroke rehabilitation settings.

METHODS, PARTICIPANTS AND ANALYSIS

A process evaluation focusing on acceptability was conducted. Individual and dyadic interviews were performed with ten stroke survivors (three women and seven men, aged 50-84) with moderate stroke and seven significant others (five women and two men, aged 50-78) post-rehabilitation. A constructivist Grounded Theory analysis was used to explore what, why, when, and how the apps worked or did not work throughout the stroke rehabilitation trajectory and if adaptions were needed.

RESULTS

Participants found that Mit Sygehus provided adequate and sufficient knowledge and was easy to use, however, acceptability of Mit Sygehus declined throughout the rehabilitation process. Also, knowledge on 'return-to-work' and 're-gaining driver's license/permission to drive' needed to be developed. The content in Genoptræn.dk was perceived as acceptable, through content being person-centred, motivating and meaningful. Genoptræn.dk furthermore, supported the transfer between rehabilitation settings, provided a sense of progress throughout the rehabilitation process, facilitated positive habits regarding self-training, and relieved the burden on significant others. Genoptræn.dk was perceived most acceptable in the sub-acute rehabilitation setting and declined when rehabilitation continued in the municipal setting.

CONCLUSION

Stroke survivors and their significant others found Mit Sygehus and Genoptræn.dk acceptable to support cross-sectoral, person-centred and empowering stroke rehabilitation, however acceptability declined throughout the rehabilitation process. Further investigations are required to determine how cognitive rehabilitation can play a greater role in app-supported stroke rehabilitation and how the need for more long-term follow-up can be supported.

Enhancing neurocognitive health, abilities, networks, & community engagement for older adults with cognitive impairments through technology: a scoping review introducing the ENHANCE Center

PURPOSE

Age associated cognitive impairments (CIs) result in difficulties with a wide range of daily activities. As the older adult population increases, so does the importance of understanding and supporting the needs and disabilities of those with CIs. The Enhancing Neurocognitive Health, Abilities, Networks, and Community Engagement (ENHANCE) Centre was established with a focus on developing assistive technology to support the socialisation, transportation, and prospective memory needs of older adults with CIs. The extent to which relevant literature in these domains existed was unknown.

MATERIALS AND METHODS

A scoping review identified existing research meeting the following criteria: participants aged 50+ years classified as having a CI due to mild cognitive impairment (MCI), traumatic brain injury (TBI), or stroke; and a focus on technology-based support for socialisation, transportation, and/or prospective memory activities.

RESULTS

Qualitative and quantitative data are reported from relevant studies. In addition to few studies available, it was common for studies to include 20 or fewer participants. Most assessed technology interactions at one time and few studies examined longitudinal use and benefit. While each paper examined one aspect of user-centred design, no technologies were reported that underwent all stages of the user-centred design process, from needs assessment to iterative design and usability testing, to efficacy trial.

CONCLUSIONS

Gaps highlight notable directions for future research and the important role ENHANCE can play in addressing the needs and disabilities of older adults with CIs. IMPLICATIONS FOR REHABILITATIONAlthough older adults with common cognitive impairments often experience challenges in the domains of socialisation, transportation, and/or prospective memory, few studies exist that examine assistive technology solutions in these domains.Additional research with more robust designs and larger sample sizes is needed to discover and assess assistive technology solutions for the needs and disabilities of older adults with mild cognitive impairment (MCI), traumatic brain injury (TBI), and post-stroke cognitive impairment (PSCI).The ENHANCE Centre will employ a systematic process of needs assessments, user testing, and efficacy tests to develop novel technology solutions to support the needs of older adults with common cognitive impairment.

Use of Information and Communication Technology by South Korean Occupational Therapists Working in Hospitals: A Cross-Sectional Study

The convergence and development of information and communication technology (ICT) have brought changes to occupational therapy practices, posing novel challenges for occupational therapists (OTs). This study aimed to investigate current practices of ICT use and factors affecting the clinical use of ICT among Korean OTs. An online survey was conducted among 158 domestic OTs working in hospitals. Participants reported that the therapeutic use of ICT positively affected client outcomes, ICT choice, and continued use. Participants highlighted the necessity to assess the ability of clients to use smart devices and ensure familiarity in the OT process. Of respondents, 31% reported the application of ICT-based interventions or recommendations in clinical practice. The use of ICT was predominantly associated with cognitive function, leisure activities, and information access and communication. A significant difference in barriers to ICT use was observed between familiar users and non-users. Familiar users reported a lack of knowledge and training as major barriers, whereas non-users reported expensive products or technology. Ease of use and usefulness were facilitators of ICT use among familiar users. Information and training opportunities are required to promote ICT use by OTs, and the usefulness of ICT must be realized via client-centered, customized approaches.

Physiotherapists' and occupational therapists' perspectives on information and communication technology in stroke rehabilitation

Aim

The aim of this study was to explore the current and potential use of information and communication technology (ICT) to enhance coherent person-centred rehabilitation after stroke, from the perspectives of physiotherapists and occupational therapists.

Method

Five occupational therapists and four physiotherapists from different phases of the Danish stroke rehabilitation process were included and two focus group interviews were carried out. A grounded theory approach was used throughout the study and a constant comparative method was used in the analysis.

Results

Three subcategories were identified from the analysis of interviews with participants: 1) ICT and apps as meaningful and supportive in the rehabilitation process, 2) ICT as a tool in communication and documentation and 3) Barriers to the integration of ICT and apps in the rehabilitation process. From these categories one core category emerged: The potential of a personalized app solution to facilitate coherent person-centred rehabilitation.

Conclusion

ICT was perceived as important to integrate in stroke rehabilitation both for assessment, training and to compensate for remaining deficits. The development of a personalized app solution could accommodate stroke survivors’ and significant others’ need for insight into and overview over the rehabilitation process as well as access to relevant information, which would thereby empower them. Furthermore, a personalized app solution could also facilitate follow-up after discharge and was perceived to ease the communication and documentation within and between sectors, as well as communication with both stroke survivors and significant others.

What's in it for me? A process evaluation of the implementation of a mobile phone-supported intervention after stroke in Uganda

BACKGROUND

The prevalence of stroke in Uganda is increasing. In stroke rehabilitation, information and communication technology has been shown to have potential in improving service delivery in high-income countries but there is limited knowledge of its use and impact in low-income countries. The aim of the study was to evaluate the implementation process of a mobile phone-supported family-centred rehabilitation intervention and to gain knowledge on the mechanisms of impact as well as the contextual factors that might have affected the implementation process and its outcome.

METHOD

This was a single-case study design using the integrated Promoting Action on Research Implementation in Health Services framework and the Medical Research Council guidance as frameworks. Quantitative process data was derived from 14 log books used by occupational therapists during the implementation. Qualitative semi-structured interviews were conducted with 12 implementers in different professions, 12 months into the implementation, in order to obtain the primary data. Secondary data was derived from six semi-structured interviews conducted directly after pre-intervention workshops and 6 months later. The framework method was used in the data analysis.

RESULTS

In 11 out of 14 cases, the clients were compliant with the intervention. Yet, challenges such as technical problems were reported. The target of conducting 16 phone calls for each client was achieved to 74%. Eight categories emerged from the qualitative analysis of the interviews including: 1) perceptions on facilitation, 2) using scientific and experience-based knowledge, 3) tailoring the intervention, 4) supportive working culture, 5) barriers to the service delivery, 6) implementers' interaction with the intervention, 7) perceptions on motivations and values, and 8) improving the model and enabling sustainability. Mechanisms contributing to the implementation of the intervention included engaged facilitators and motivated participants. Challenges in the client recruitment and poor information dissemination were some of the mechanisms impeding the implementation.

CONCLUSIONS

The intervention was partially delivered in accordance with the logic model for the project, where the implementation process was influenced by several barriers in the context such as technical setbacks. However, there were also several mediators in the process driving the project forward, including strong facilitation and motivated participants.

Methods to evaluate perspectives of safety, independence, activity, and participation in older persons using welfare technology. A systematic review

Purpose: To conduct a systematic review of existing methods to evaluate the individual aspects of welfare technology from the perspectives of independence, safety, activity, and participation. Furthermore, the study aimed to describe outcomes that have been the focus of previous research to evaluate individual aspects of welfare technology in older persons living in ordinary housing. Materials and methods: A systematic literature review in PubMed, CINAHL Plus, PsycINFO, Scopus, and Web of Science. Studies selected were those that explored the use of assistive and welfare technology devices from older persons' perspectives, and which considered the concepts of independence, safety, activity and participation, and quality of life. Results: A broad spectrum of instruments was applied in the studies. For independence, three questionnaires were used in the identified studies. For safety, one instrument was used in two versions. To study activity and participation as well as quality of life, several scales were used. Additionally, several studies included qualitative approaches for evaluation, such as interviews, or posed one or more questions regarding the effects of welfare technology. Conclusions: The integration of digital assistive and welfare technology should be based on the needs of older persons, and those needs must be assessed using reliable and relevant instruments. The heterogeneity of the target group, i.e., older persons, together with the fact that assessments must give consideration to identifying goals, obstacles, and risks as well as users' preferences, implies a person-centred approach.Implications for rehabilitationThe integration of digital assistive and welfare technology should be based on older persons' needs, and those needs must be assessed using reliable and relevant instruments.The heterogeneity of the target group, i.e. older persons, together with the fact that assessments must give consideration to identifying goals, obstacles and risks as well as users' preferences, implies a person-centred approach.The ideal would be one coherent model that explores the use of digital assistive and welfare technology from the individual, economic as well as organisational dimensions. This would cover the different needs and expectations of various stakeholders, including economic and organisational, but also the needs of the older person.

Motivators and barriers to using information and communication technology in everyday life following stroke: a qualitative and video observation study

Purpose: Information and communication technology devices have become a ubiquitous part of everyday life and a primary means of communication. The aim of this study was to describe the experience of information and communication technology and to explore the barriers and motivators to its use following stroke.Materials and methods: This observational study used semi-structured individual interviews and video observation of information and communication technology device use with six people, four men, and two women age 60-82 years with upper limb disability following stroke. They were analyzed using thematic analysis.Results: Three themes were identified that relate to barriers: (i) Sensory and motor impairments; (ii) Limited vision and impaired speech; and (iii) Device-specific limitations. Six themes were identified as motivators: (i) Connect with others; (ii) Provide safety; (iii) Facilitate reintegration; (iv) Reinforce technology adoption; (v) Leisure activities; and (vi) Contribute to the rehabilitation process.Conclusion: All participants used some form of information and communication technology daily to promote safety, enable daily activities, and social interaction, and to a lesser extent engage in leisure and rehabilitation activities. Barriers to information and communication technology use were primarily related to stroke related impairments and device-specific requirements, which limited use, particularly of smartphones. These barriers should be addressed to facilitate the use of information and communication technology devices.Implications for rehabilitationThis research suggests that;People with stroke are highly motivated to use information and communication technology devices in daily activitiesStroke-specific and age-related impairments limit the use and functionality of information and communication technology devices for people with strokeInformation and communication technology devices do not appear to be promoted or used in the rehabilitation or as assistive technologies.

Significant others' perspectives on person-centred information and communication technology in stroke rehabilitation - a grounded theory study

Aim: The aim of this study was to explore significant others' perspectives on how information and communication technology can support the rehabilitation process after stroke and facilitate participation in everyday life.Method: Thirteen significant others were included in the study, and to capture their perspectives, two focus groups, and five individual interviews were carried out in Denmark and Sweden 6-12 months after the stroke incident. A grounded theory approach was used throughout the study and a constant comparative method was used in the analysis.Results: Five subcategories were identified from the analysis of the interviews: (1) Information and communication technology providing a sense of security, (2) Information and communication technology as a social mediator, (3) Information and communication technology as a compensator for deficits, (4) Information and communication technology as a way to reach information, and (5) Information and communication technology as a possibility to supplement the rehabilitation process. From these categories, one core category emerged: The potential of information and communication technology to facilitate participation in everyday life and thereby reduce the strains that significant others experience after stroke.Conclusion: Information and communication technology has the potential to facilitate participation in everyday life after stroke. It is important, therefore, to start using information and communication technology in the rehabilitation process after stroke, to bring meaning to everyday life and to support both the stroke survivors and their significant others.IMPLICATIONS FOR REHABILITATIONIntegration of information and communication technology in the rehabilitation process after stroke can accommodate several of the significant others´ needs.Educating stroke survivors to use information and communication technology as part of the rehabilitation process offloads their significant others.Integration of information and communication technology in the rehabilitation process after stroke can bring new meaning in everyday life and can facilitate both independence and participation in everyday life.

A Game Changer: 'The Use of Digital Technologies in the Management of Upper Limb Rehabilitation'

Hemiparesis is a symptom of residual weakness in half of the body, including the upper extremity, which affects the majority of post stroke survivors. Upper limb function is essential for daily life and reduction in movements can lead to tremendous decline in quality of life and independence. Current treatments, such as physiotherapy, aim to improve motor functions, however due to increasing NHS pressure, growing recognition on mental health, and close scrutiny on disease spending there is an urgent need for new approaches to be developed rapidly and sufficient resources devoted to stroke disease. Fortunately, a range of digital technologies has led to revived rehabilitation techniques in captivating and stimulating environments. To gain further insight, a meta-analysis literature search was carried out using the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) method. Articles were categorized and pooled into the following groups; pro/anti/neutral for the use of digital technology. Additionally, most literature is rationalised by quantitative and qualitative findings. Findings displayed, the majority of the inclusive literature is supportive of the use of digital technologies in the rehabilitation of upper extremity following stroke. Overall, the review highlights a wide understanding and promise directed into introducing devices into a clinical setting. Analysis of all four categories; (1) Digital Technology, (2) Virtual Reality, (3) Robotics and (4) Leap Motion displayed varying qualities both-pro and negative across each device. Prevailing developments on use of these technologies highlights an evolutionary and revolutionary step into utilizing digital technologies for rehabilitation purposes due to the vast functional gains and engagement levels experienced by patients. The influx of more commercialised and accessible devices could alter stroke recovery further with initial recommendations for combination therapy utilizing conventional and digital resources.

Do Smartphones have the Potential to Support Cognition and Independence Following Stroke?

Management of cognitive difficulties is a significant unmet need for individuals with stroke. Incorporating multiple functions, including memory aids and communication tools, smartphones have potential to improve everyday cognitive function and independence in daily activities post-stroke. We aimed to investigate patterns of smartphone use, facilitators and barriers to use, and relationships between smartphone use and daily functioning. Twenty-nine participants with stroke and 29 comparison participants with no history of neurological conditions completed measures of smartphone use, objective and subjective cognitive function, mood and community integration. The majority of participants used smartphones, though the proportion of users was lower in the stroke group (62%) than the comparison group (86%). Older participants were less likely to use smartphones. Using apps that support memory was a main benefit of smartphone use post-stroke. In the stroke group, frequent users of memory apps had significantly fewer motor symptoms (d = 1.20), and higher productivity (d = 0.84). Stroke survivors identified difficulty learning how to use smartphones, but only one participant had assistance with this from a clinician. These results suggest that smartphones have potential as assistive technology post-stroke, however, support in using them is essential, particularly for older individuals with motor dysfunction.

What environmental factors influence resumption of valued activities post stroke: a systematic review of qualitative and quantitative findings

OBJECTIVE

Identify the environmental factors that influence stroke-survivors' reengagement in personally valued activities and determine what specific environmental factors are related to specific valued activity types.

DATA SOURCES

PubMed, CINAHL and PsycINFO were searched until June 2016 using multiple search-terms for stroke, activities, disability, and home and community environments.

REVIEW METHODS

An integrated mixed-method systematic review of qualitative, quantitative and mixed-design studies was conducted. Two researchers independently identified relevant studies, assessed their methodological quality and extracted relevant findings. To validly compare and combine the various findings, all findings were classified and grouped by environmental category and level of evidence.

RESULTS

The search yielded 4024 records; 69 studies were included. Most findings came from low-evidence-level studies such as single qualitative studies. All findings were consistent in that the following factors facilitated reengagement post-stroke: personal adapted equipment; accessible environments; transport; services; education and information. Barriers were: others' negative attitudes and behaviour; long distances and inconvenient environmental conditions (such as bad weather). Each type of valued activity, such as mobility or work, had its own pattern of environmental influences, social support was a facilitator to all types of activities. Although in many qualitative studies others' attitudes, behaviour and stroke-related knowledge were seen as important for reengagement, these factors were hardly studied quantitatively.

CONCLUSION

A diversity of environmental factors was related to stroke-survivors' reengagement. Most findings came from low-evidence-level studies so that evidence on causal relationships was scarce. In future, more higher-level-evidence studies, for example on the attitudes of significant others, should be conducted.

Activities people with cognitive deficits want to continue mastering – A scoping study

Introduction

To date, potential difficulties that people with cognitive deficits meet in everyday life are relatively well known, but in which activities mastery is desired, and why, is less researched. The aim of this study was to develop deeper knowledge about activities that people with cognitive deficits want to continue mastering in everyday life and the reasons why these activities were desired.

Method

In the frame of a scoping study, articles were gathered and charted. Sixteen qualitative studies were selected as meeting the aim of the study and analyzed with a descriptive-interpretative method.

Findings

The analysis of the studies showed that the desired activities conveyed social values or independence, supported significant roles, diminished negative influence on other people, and increased health and safety. Linkages, in the form of dependencies between the desired activities, were also identified.

Conclusion

When planning for interventions for facilitating everyday activities, for example with technology, it is beneficial to consider both safety and values that are more closely related to meaningfulness and wellbeing. Most difficult activities were identified as hindering outdoor activities, and targeting those activities might be most valuable for enabling active everyday lives for this group.

Role of Environmental Factors on Resuming Valued Activities Poststroke: A Systematic Review of Qualitative and Quantitative Findings

OBJECTIVE

To investigate how reengagement in valued activities poststroke is influenced by environmental factors.

DATA SOURCES

PubMed, CINAHL, and PsycINFO were searched to June 2015 using multiple search terms for stroke, activities, disability, and home and community environments, with the following constraints: English, humans, and adults.

STUDY SELECTION

Studies were included that contained data on how reengagement in valued activities of community-dwelling stroke survivors was influenced by the environment. Two reviewers independently selected the studies. The search yielded 3726 records; 39 studies were eventually included.

DATA EXTRACTION

Findings were extracted from qualitative, quantitative, and mixed-design studies. Two reviewers independently assessed study quality using the Oxford Critical Appraisal Skills Programme lists and independently extracted results.

DATA SYNTHESIS

Thematic analysis was conducted on qualitative data, revealing 9 themes related to the iterative nature of the process of reengagement and the associated environmental factors. During the process of reengagement, environmental factors interact with personal and disease-related factors in a gradual process of shaping or abandoning valued activities. The sociocultural context in this case determines what activities are valued and can be resumed by stroke survivors. Social support; activity opportunities and obligations; familiar and accessible environments; resources and reminders; and a step-by-step return facilitate stroke survivors to explore, adapt, resume, and maintain their activities. Social support is helpful at all stages of the process and particularly is important in case stroke survivors are fearful to explore their activity possibilities. The quantitative data identified largely endorsed these findings. No quantitative data were found in respect to the iterative nature of the process, familiar environments, or accessibility.

CONCLUSIONS

Reengagement in valued activities is a gradual process. In each stage of the process, several environmental factors play a role. During rehabilitation, professionals should pay attention to the role physical and social environmental factors have in reengagement poststroke and find ways to optimize stroke survivors' environments.

Rehabilitation professionals' perceptions of the use of new visualisation software tools with people with stroke

PURPOSE

The envisage programme of research was funded to explore and evaluate the use of visualisation software tools using biomechanical data within rehabilitation. Three work packages were developed to evaluate the impact of the tools within stroke rehabilitation. The research presented here aimed at exploring the perceptions of rehabilitation therapists about the use of the visualisation software tools in the context of future randomised controlled trials and stroke rehabilitation practice.

METHODS

Sixteen therapists working in a range of stroke rehabilitation contexts participated in semi-structured interviews. Interview questions explored their current practice, and the perceived impact of the new visualisation technologies on their workplace environment and practice. Framework analysis was used to analyse the textual data.

RESULTS

In general, the stroke therapists were enthusiastic about the potential application of the visualisation software tools. Three themes were identified through qualitative framework analysis: potential uses of the visualisation tools; integration within current service provision; and trial involvement.

CONCLUSIONS

The study highlights important contextual considerations which may impact significantly on the success of novel technologies in stroke rehabilitation. Normalisation process theory was proposed as a useful process evaluation methodology to optimise both trial evaluation and future service implementation. Implications for Rehabilitation There is limited research exploring the use of visual software technologies featuring biomechanical data within stroke rehabilitation. The perspectives of stroke rehabilitation therapists about the potential of such tools are useful both in terms of planning trial evaluations, and implementation. Therapists were generally positive about the contribution of visual software tools in stroke rehabilitation, but highlighted a number of practical constraints which required addressing. Normalisation process theory provides a useful process evaluation methodology which can support both trial evaluation and implementation of such novel technologies within stroke rehabilitation.

Technology-aided programs for post-coma patients emerged from or in a minimally conscious state

Post-coma persons in a minimally conscious state (MCS) or emerged/emerging from such state (E-MCS), who are affected by extensive motor impairment and lack of speech, may develop an active role and interact with their environment with the help of technology-aided intervention programs. Although a number of studies have been conducted in this area during the last few years, new evidence about the efficacy of those programs is warranted. These three studies were an effort in that direction. Study I assessed a technology-aided program to enable six MCS participants to access preferred environmental stimulation independently. Studies II and III assessed technology-aided programs to enable six E-MCS participants to make choices. In Study II, three of those participants were led to choose among leisure and social stimuli, and caregiver interventions automatically presented to them. In Study III, the remaining three participants were led to choose (a) among general stimulus/intervention options (e.g., songs, video-recordings of family members, and caregiver interventions); and then (b) among variants of those options. The results of all three studies were largely positive with substantial increases of independent stimulation access for the participants of Study I and independent choice behavior for the participants of Studies II and III. The results were analyzed in relation to previous data and in terms of their implications for daily contexts working with MCS and E-MCS persons affected by multiple disabilities.

Collaborative interaction points in post-discharge stroke care

Introduction

Lack of appropriate electronic tools for supporting patient involvement and collaboration with care professionals is a problem in health care.

Methods

Care and rehabilitation processes of post-discharge stroke patients were analysed using the concept of interaction points where patients, next-of-kin and care professionals interact and exchange information. Thirteen interviews with care professionals and five non-participatory observations were performed. Data were analysed using content analysis and modelling of interaction points in the patient journey.

Results

Patient participation and interaction patterns vary; patients requiring home care have a passive role and next-of-kin or nurses become advocates by coordinating care on behalf of the patient, whereas patients who are able to visit primary care coordinate their own care by initiating interactions. Important categories of participation include the following: participation in care planning, in monitoring risk factors and in rehabilitation planning.

Conclusions

Designing a supportive electronic tool requires understanding the interactions and patients’ activity levels at each interaction point. A tool for patients with higher activity level should support them to coordinate their own care, whereas for a less-active patient group, the tool could focus on supporting next-of-kin and care professionals in motivating, guiding and including passive patients in their care and rehabilitation processes.

Technology to help persons with extensive neuro-motor impairment and lack of speech with their leisure occupation and communication

These two studies were aimed at extending the assessment of technology-aided programs to enhance leisure occupation or communication with persons with extensive neuro-motor impairment and lack of speech. Specifically, Study I implemented the program for leisure occupation with two post-stroke patients. Study II implemented the program for communication with two persons affected by amyotrophic lateral sclerosis (ALS). In Study I, a computer system presented the participants with a variety of stimuli. The participants could select/access those stimuli by microswitch activation or could bypass them by abstaining from microswitch responses. In Study II, the participants used a computer-aided telephone system that allowed them to choose via microswitch activation the persons to call. On the computer screen, they also had words and phrases that they could activate during the calls to influence the conversation with the persons called. Data from both studies were largely positive. The post-stroke patients showed high levels of stimulus selection (access) and extended engagement. The patients with ALS were able to make phone calls and to select the words/phrases to influence the conversations. The relevance of technology-aided programs for leisure occupation and communication of persons with extensive multiple disabilities was discussed.