Sharon M. Nijenhuis

Training modalities in robot-mediated upper limb rehabilitation in stroke: a framework for classification based on a systematic review

Robot-mediated post-stroke therapy for the upper-extremity dates back to the 1990s. Since then, a number of robotic devices have become commercially available. There is clear evidence that robotic interventions improve upper limb motor scores and strength, but these improvements are often not transferred to performance of activities of daily living. We wish to better understand why. Our systematic review of 74 papers focuses on the targeted stage of recovery, the part of the limb trained, the different modalities used, and the effectiveness of each. The review shows that most of the studies so far focus on training of the proximal arm for chronic stroke patients. About the training modalities, studies typically refer to active, active-assisted and passive interaction. Robot-therapy in active assisted mode was associated with consistent improvements in arm function. More specifically, the use of HRI features stressing active contribution by the patient, such as EMG-modulated forces or a pushing force in combination with spring-damper guidance, may be beneficial.Our work also highlights that current literature frequently lacks information regarding the mechanism about the physical human-robot interaction (HRI). It is often unclear how the different modalities are implemented by different research groups (using different robots and platforms). In order to have a better and more reliable evidence of usefulness for these technologies, it is recommended that the HRI is better described and documented so that work of various teams can be considered in the same group and categories, allowing to infer for more suitable approaches. We propose a framework for categorisation of HRI modalities and features that will allow comparing their therapeutic benefits.

Design, development and deployment of a hand/wrist exoskeleton for home-based rehabilitation after stroke - SCRIPT project

Objective: this manuscript introduces the Supervised Care and Rehabilitation Involving Personal Tele-robotics (SCRIPT) project. The main goal is to demonstrate design and development steps involved in a complex intervention, while examining feasibility of using an instrumented orthotic device for home-based rehabilitation after stroke. Methods: the project uses a user-centred design methodology to develop a hand/wrist rehabilitation device for home-based therapy after stroke. The patient benefits from a dedicated user interface that allows them to receive feedback on exercise as well as communicating with the health-care professional. The health-care professional is able to use a dedicated interface to send/receive communications and remote-manage patients exercise routine using provided performance benchmarks. Patients were involved in a feasibility study (n=23) and were instructed to use the device and its interactive games for 180 min per week, around 30 min per day, for a period of 6 weeks, with a 2-months follow up. At the time of this study, only 12 of these patients have finished their 6 weeks trial plus 2 months follow up evaluation. Results: with the “use feasibility” as objective, our results indicate 2 patients dropping out due to technical difficulty or lack of personal interests to continue. Our frequency of use results indicate that on average, patients used the SCRIPT1 device around 14 min of self-administered therapy a day. The group average for the system usability scale was around 69% supporting system usability. Conclusions: based on the preliminary results, it is evident that stroke patients were able to use the system in their homes. An average of 14 min a day engagement mediated via three interactive games is promising, given the chronic stage of stroke. During the 2nd year of the project, 6 additional games with more functional relevance in their interaction have been designed to allow for a more variant context for interaction with the system, thus hoping to positively influence the exercise duration. The system usability was tested and provided supporting evidence for this parameter. Additional improvements to the system are planned based on formative feedback throughout the project and during the evaluations. These include a new orthosis that allows a more active control of the amount of assistance and resistance provided, thus aiming to provide a more challenging interaction.

The experience of living with stroke and using technology : opportunities to engage and co-design with end users

Abstract Purpose: We drew on an interdisciplinary research design to examine stroke survivors’ experiences of living with stroke and with technology in order to provide technology developers with insight into values, thoughts and feelings of the potential users of a to-be-designed robotic technology for home-based rehabilitation of the hand and wrist. Method: Ten stroke survivors and their family carers were purposefully selected. On the first home visit, they were introduced to cultural probe. On the second visit, the content of the probe packs were used as prompt to conduct one-to-one interviews with them. The data generated was analysed using thematic analysis. A third home visit was conducted to evaluate the early prototype. Results: User requirements were categorised into their network of relationships, their attitude towards technology, their skills, their goals and motivations. The user requirements were used to envision the requirements of the system including providing feedback on performance, motivational aspects and usability of the system. Participants’ views on the system requirements were obtained during a participatory evaluation. Conclusion: This study showed that prior to the development of technology, it is important to engage with potential users to identify user requirements and subsequently envision system requirements based on users’ views. Implications for Rehabilitation An understanding of how stroke survivors make sense of their experiences of living with stroke is needed to design home-based rehabilitation technologies. Linking stroke survivors’ goals, motivations, behaviour, feelings and attitude to user requirements prior to technology development has a significant impact on improving the design.

User-centred input for a wearable soft-robotic glove supporting hand function in daily life

Many stroke patients and elderly have a reduced hand function, resulting in difficulties with independently performing activities of daily living (ADL). Assistive technology is a promising alternative to support the upper limb in performing ADL. To avoid device abandonment, end-users should be involved early in the design and development phase to identify user requirements for assistive technology. The present study applies a user-centred approach to identify user requirements for wearable soft-robotic gloves targeted at physical support of hand function during ADL for elderly and stroke patients. Elderly, stroke patients and healthcare professionals, participating in focus groups, specified requirements regarding: 1) activities that need support of assistive technology, 2) design of wearable robotic devices for hand support, and 3) application of assistive technology as training tool at home. Assistive technology for the support of the hand is considered valuable by users for assisting ADL, but only if the device is wearable, compact, lightweight, easy to use, quickly initialized, washable and only supports the particular function(s) that an individual need(s) assistance with, without taking over existing function(s) from the user.

Effects of training with a passive hand orthosis and games at home in chronic stroke: a pilot randomised controlled trial

Objectives: To compare user acceptance and arm and hand function changes after technology-supported training at home with conventional exercises in chronic stroke. Secondly, to investigate the relation between training duration and clinical changes. Design: A randomised controlled trial. Setting: Training at home, evaluation at research institute. Subjects: Twenty chronic stroke patients with severely to mildly impaired arm and hand function. Interventions: Participants were randomly assigned to six weeks (30 minutes per day, six days a week) of self-administered home-based arm and hand training using either a passive dynamic wrist and hand orthosis combined with computerised gaming exercises (experimental group) or prescribed conventional exercises from an exercise book (control group). Main measures: Main outcome measures are the training duration for user acceptance and the Action Research Arm Test for arm and hand function. Secondary outcomes are the Intrinsic Motivation Inventory, Fugl-Meyer assessment, Motor Activity Log, Stroke Impact Scale and grip strength. Results: The control group reported a higher training duration (189 versus 118 minutes per week, P = 0.025). Perceived motivation was positive and equal between groups (P = 0.935). No differences in clinical outcomes over training between groups were found (P ⩾ 0.165). Changes in Box and Block Test correlated positively with training duration (P = 0.001). Conclusions: Both interventions were accepted. An additional benefit of technology-supported arm and hand training over conventional arm and hand exercises at home was not demonstrated. Training duration in itself is a major contributor to arm and hand function improvements.

Technical evaluation of and clinical experiences with the SCRIPT passive wrist and hand orthosis

Rehabilitation robots are useful tools to objectively quantify and treat post-stroke impairments. The SCRIPT Passive Orthosis (SPO) is an passively actuated hand orthosis that can be used for interactive therapy at home. In the last year the SPO was used independently by 24 patients in three EU countries. In this paper we report on the technical challenges this has presented and the feedback we were given by therapists and patients. This includes the range-of-motion of the device, the assistive characteristics, the potential for grasp detection, and the user acceptance.

Lag-lead based assessment and adaptation of exercise speed for stroke survivors

The SCRIPT project aims at delivering machine-mediated hand and wrist exercises to people with stroke in their homes. In this context, adapting the exercise to the individual needs potentially enhances recovery.We designed a system composed of a passive-actuated wearable device, a personal computer and an arm support. The system enables users to exercise their hand and wrist movements by playing interactive games which were developed as part of the project. Movements and their required speed are tailored on the individuals capabilities. During the exercise the system assesses whether the subject is in advance (leading) or in delay (lagging) with respect to a reference trajectory. This information provides input to an adaptive mechanism which changes the required movement speed in order to make the exercise neither too easy nor too challenging.In this paper, we show results of the adaptation process in a study involving seven persons with chronic stroke who completed a six weeks training in their homes. Based on the patterns observed in difficulty and lag-lead score, we defined five session types (challenging, challenging-then supporting, supporting, under-supporting and under-challenging). We show that the mechanism of adaptation has been effective in 195 of 248 (78.6%) sessions.Based on our results, we propose the lag-lead based assessment and adaptation as an auto-tuning tool for machine based exercise, with particular focus on rehabilitation robotics. Also, the classification of sessions among different types can be applied to other studies in order to better understanding the progression of therapy in order to maximize its outcome. Our system enabled people with stroke to exercise at home by playing videogames.Movement speed was adapted to performance, based on the Optimal Challenge Framework.The mechanism of adaptation has been effective in 195 of 248 (78.6%) sessions.The efficacy of the adaptation mechanism led subjects to train more intensively.Lag-lead based adaptation is a suitable auto-tuning tool for robot therapy.

Preliminary Findings of Feasibility and Compliance of Technology-Supported Distal Arm Training at Home after Stroke

After stroke, intensive and active training is important to regain functional use of the arm and hand. By applying a telerehabilitation system (SCRIPT1) supporting active, distal arm practice at home, a patient can practice independently, which enables a larger dosage of treatment than possible during one-to-one supervised rehabilitation. Currently one of the major, but rarely addressed, questions concerning telerehabilitation is whether patients actually use such a system in a self-administered training approach. This paper presents preliminary results about feasibility of self-administered post-stroke home-based SCRIPT1 training. So far, data of 20 chronic stroke patients is available, who have trained for six weeks at home using interactive gaming exercises and a passive wrist/hand orthosis supporting hand opening (SCRIPT1). Findings so far indicated positive perceptions of usability and showed actual use of the system with a mean training duration of 107 min/week. This was accompanied by modest improvements in motor function and dexterity, correlated positively with training duration. These preliminary findings indicate that self-administered, technology-supported distal arm training at home is feasible for chronic stroke patients.

Exploring Relations between Functional Task Kinematics and Clinical Assessment of Arm Function and Dexterity Post-stroke

After stroke, technology-supported treatment, enables more independent, self-administered exercises of the arm. Preferably, such treatment is applied in the home setting, to enable increase of treatment dosage. Although such interventions are effective to improve motor function of the affected arm, their influence on functional abilities is less understood. The present paper examines which motor control limitations are related to limitations in arm and hand function in stroke patients. A functional reach and grasp task has been performed by 14 chronic stroke patients, during which kinematic parameters were recorded, in addition to maximal grip strength. Also, clinical assessments of arm function and dexterity were done. Peak hand speed, elbow extension range, maximal hand opening and grip strength correlated strongly with clinically assessed sensorimotor arm function and dexterity in mildly to severely affected chronic stroke patients (ρ=0.66-0.85), whereas trunk displacement showed a weaker correlation (ρ=-0.50). The present findings suggest that it may be valuable for treatment applications in neurorehabilitation for stroke to focus on at least movement speed and movement coordination for both the proximal and distal arm in order to stimulate functional improvements.

Strong relations of elbow excursion and grip strength with post-stroke arm function and activities: Should we aim for this in technology-supported training?

Objective To investigate the relationships between an extensive set of objective movement execution kinematics of the upper extremity and clinical outcome measures in chronic stroke patients: at baseline and after technology-supported training at home. Methods Twenty mildly to severely affected chronic stroke patients participated in the baseline evaluation, 15 were re-evaluated after six weeks of intensive technology-supported or conventional arm/hand training at home. Grip strength, 3D motion analysis of a reach and grasp task, and clinical scales (Fugl-Meyer assessment (FM), Action Research Arm Test (ARAT) and Motor Activity Log (MAL)) were assessed pre- and post-training. Results Most movement execution parameters showed moderate-to-strong relationships with FM and ARAT, and to a smaller degree with MAL. Elbow excursion explained the largest amount of variance in FM and ARAT, together with grip strength. The only strong association after training was found between changes in ARAT and improvements in hand opening (conventional) or grip strength (technology-supported). Conclusions Elbow excursion and grip strength showed strongest association with post-stroke arm function and activities. Improved functional ability after training at home was associated with increased hand function. Addressing both reaching and hand function are indicated as valuable targets for (technological) treatment applications to stimulate functional improvements after stroke.