Ruth Turk

A design framework for a home-based stroke rehabilitation system: Identifying the key components

We present a design framework for a sensor-based stroke rehabilitation system for use at home developed through the analysis of data collected from a series of workshops. Participants had a variety of backgrounds and included people living with stroke and health professionals who work with them. Our focus in these workshops was to learn more about the social context around stroke care, to share early project ideas and develop a design framework for developing systems. In this paper we present a detailed analysis of participant responses and use this analysis to draw specific conclusions about the components and configuration that we believe should be in future systems.

Translation of evidence-based Assistive Technologies into stroke rehabilitation: users' perceptions of the barriers and opportunities

BackgroundAssistive Technologies (ATs), defined as “electrical or mechanical devices designed to help people recover movement”, demonstrate clinical benefits in upper limb stroke rehabilitation; however translation into clinical practice is poor. Uptake is dependent on a complex relationship between all stakeholders. Our aim was to understand patients’, carers’ (P&Cs) and healthcare professionals’ (HCPs) experience and views of upper limb rehabilitation and ATs, to identify barriers and opportunities critical to the effective translation of ATs into clinical practice. This work was conducted in the UK, which has a state funded healthcare system, but the findings have relevance to all healthcare systems.MethodsTwo structurally comparable questionnaires, one for P&Cs and one for HCPs, were designed, piloted and completed anonymously. Wide distribution of the questionnaires provided data from HCPs with experience of stroke rehabilitation and P&Cs who had experience of stroke. Questionnaires were designed based on themes identified from four focus groups held with HCPs and P&Cs and piloted with a sample of HCPs (N = 24) and P&Cs (N = 8). Eight of whom (four HCPs and four P&Cs) had been involved in the development.Results292 HCPs and 123 P&Cs questionnaires were analysed. 120 (41%) of HCP and 79 (64%) of P&C respondents had never used ATs. Most views were common to both groups, citing lack of information and access to ATs as the main reasons for not using them. Both HCPs (N = 53 [34%]) and P&C (N = 21 [47%]) cited Functional Electrical Stimulation (FES) as the most frequently used AT. Research evidence was rated by HCPs as the most important factor in the design of an ideal technology, yet ATs they used or prescribed were not supported by research evidence. P&Cs rated ease of set-up and comfort more highly.ConclusionKey barriers to translation of ATs into clinical practice are lack of knowledge, education, awareness and access. Perceptions about arm rehabilitation post-stroke are similar between HCPs and P&Cs. Based on our findings, improvements in AT design, pragmatic clinical evaluation, better knowledge and awareness and improvement in provision of services will contribute to better and cost-effective upper limb stroke rehabilitation.

Therapeutic Effectiveness of Electric Stimulation of the Upper-Limb Poststroke Using Implanted Microstimulators

OBJECTIVE To investigate the therapeutic effect of functional exercise augmented by programmable implanted microstimulators on arm and hand function. DESIGN Before and after study. SETTING Implantation was performed in a neurosurgery unit, systems were programmed, and tests were conducted in a university laboratory and subjects exercised at home. PARTICIPANTS Hemiparetic subjects (N=7) with reduced upper-limb function who were at least 12 months poststroke were recruited from the community. No subjects withdrew. INTERVENTION Microstimulators were implanted into the arms and forearms to activate elbow, wrist, and finger extension, and thumb abduction. After training and programming of the system, subjects underwent 12 weeks of functional home-based exercise with stimulation. MAIN OUTCOME MEASURES The primary functional measure was the Action Research Arm Test (ARAT). Impairment measures included upper-limb Fugl-Meyer Assessment (FMA) and tests of motor control (tracking index), spasticity (electromyography stretch index) strength, and active range of motion (AROM). The assessor was not blinded, but scores were validated by an independent blinded observer. RESULTS All subjects were able to perform functional activities at home by using the system. Compliance was excellent, and there were no serious adverse events. Statistically significant improvements were measured (P<.05) in the tracking index (57.3 degrees(2)+/-48.65 degrees(2)), FMA score (6.3+/-3.59), wrist-extensor strength (5.5+/-4.37 N), and wrist AROM (19.3 degrees +/-18.96 degrees). The mean improvement in ARAT score +/- SD of 4.9+/-7.89 was not statistically significant. CONCLUSIONS This study has shown the feasibility of a programmable implanted microstimulator system used at home to perform functional exercises and a reduction in impairment after 12 weeks.

Reliability and Sensitivity of a Wrist Rig to Measure Motor Control and Spasticity in Poststroke Hemiplegia

Background. Objective assessment of impairments after stroke is vital for evidence-based therapy and progress monitoring. Objective. This study determines the utility of outcome measures obtained from an instrumented wrist rig for future rehabilitation trials. The tests undertaken were evaluated in terms of sensitivity to detect differences between normal and impaired participants, test-retest repeatability (repeatability coefficient and intraclass correlation coefficient [ICC]), and interrater agreement (Bland and Altman limits of agreement). Methods . Twelve participants with chronic poststroke hemiparesis (mean 5.6 years); and 12 unimpaired volunteers performed a series of tasks in the rig. The hemiparetic arm (impaired group) and dominant arm (unimpaired group) were tested in 3 sessions on the same day by 2 assessors. Signals were analyzed to derive a tracking index (motor control), stretch index (spasticity), flexor modulation index (FMI) (muscle activation), force angle index (FAI) (stiffness), range of movement, and isometric force. Results and Conclusions. The means of all tests differed between impaired and unimpaired participants except for range of movement into flexion, the FAI, and the FMI. Repeatability coefficients for each test are presented as benchmark values for use in future trials in which the wrist rig tests may be used to detect change. Test-retest reliability was excellent in the impaired group (ICC = 0.88-0.98) and poor to excellent in the unimpaired group (ICC = 0.06-0.89). The Bland-Altman ranges showed no bias between assessors, and that the interassessor variability was similar to that between repeats by the same assessor for most tests.

The relationship between upper limb activity and impairment in post-stroke hemiplegia

Purpose. To investigate the relationship between upper limb impairments and activity limitation. Method. A cross sectional, single assessment observational study in which people with hemiplegia as a result of a stroke underwent a testing procedure in an instrumented wrist rig in which the following measures of impairment were recorded: Spasticity; motor control (ability to track a moving target); muscle activation patterns during tracking; stiffness; range of active movement and isometric muscle strength. Participants also performed clinical tests of upper limb activity (Action Research Arm Test) and hyper-tonicity (Modified Ashworth Scale). Results. Seventeen people with hemiplegia whose mean age was 57 (SD 13.4) took part. Their mean upper limb activity, measured by the Action Research Arm Test, was 19.3 (SD 11.2). Statistically significant positive relationships between level of activity and the negative features of the upper motor neuron syndrome such as motor control r = 0.710 (p = 0.003), active range of movement r = 0.540 (p = 0.025) and strength into flexion r = 0.515 (p = 0.034) and extension r = 0.575 (p = 0.016) were identified, but not with the positive features, such as spasticity or the secondary features such as stiffness. Conclusions. The negative features of the upper motor neuron syndrome appear more likely to affect upper limb activity than the positive or secondary features, but findings need confirming in different study populations, preferably with larger samples.

A Personalized Sensor‐Controlled Microstimulator System for Arm Rehabilitation Poststroke. Part 1: System Architecture

Objectives:  For rehabilitation of the poststroke upper limb in seven subjects, an external sensor‐based system controls the timing of five to seven microstimulators implanted near radial nerve branches or their motor points to sequentially extend the elbow, wrist, and fingers with thumb extension and abduction, enabled at the subjects own pace. We hypothesize this system will support sequential activation of affected upper limb muscles intended to improve functional recovery.

The association between muscle activation patterns, wrist tracking performance and upper limb function in post-stroke hemiplegia

The Society of Research in Rehabilitation (SRR) is the major multidisciplinary rehabilitation research society in the UK (http://www.srr.org.uk). Its aim is to advance education and research into all aspects of rehabilitation medicine and to disseminate the useful results of such research for the public benefit. The SRR runs two conferences a year, with topic-specific research symposia, free scientific presentations and ‘research in progress’ posters. The Society aims to be inspiring and educational, while providing excellent opportunities for networking for both junior and established researchers. These are abstracts from the SRR Summer Meeting, hosted by the University of Bath, 1st and 2nd July 2009.