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.

Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke.

BACKGROUND: Assistive and robotic training devices are increasingly used for rehabilitation of the hemiparetic arm after stroke, although applications for the wrist and hand are trailing behind. Furthermore, applying a training device in domestic settings may enable an increased training dose of functional arm and hand training. The objective of this study was to assess the feasibility and potential clinical changes associated with a technology-supported arm and hand training system at home for patients with chronic stroke. METHODS: A dynamic wrist and hand orthosis was combined with a remotely monitored user interface with motivational gaming environment for self-administered training at home. Twenty-four chronic stroke patients with impaired arm/hand function were recruited to use the training system at home for six weeks. Evaluation of feasibility involved training duration, usability and motivation. Clinical outcomes on arm/hand function, activity and participation were assessed before and after six weeks of training and at two-month follow-up. RESULTS: Mean System Usability Scale score was 69 % (SD 17 %), mean Intrinsic Motivation Inventory score was 5.2 (SD 0.9) points, and mean training duration per week was 105 (SD 66) minutes. Median Fugl-Meyer score improved from 37 (IQR 30) pre-training to 41 (IQR 32) post-training and was sustained at two-month follow-up (40 (IQR 32)). The Stroke Impact Scale improved from 56.3 (SD 13.2) pre-training to 60.0 (SD 13.9) post-training, with a trend at follow-up (59.8 (SD 15.2)). No significant improvements were found on the Action Research Arm Test and Motor Activity Log. CONCLUSIONS: Remotely monitored post-stroke training at home applying gaming exercises while physically supporting the wrist and hand showed to be feasible: participants were able and motivated to use the training system independently at home. Usability shows potential, although several usability issues need further attention. Upper extremity function and quality of life improved after training, although dexterity did not. These findings indicate that home-based arm and hand training with physical support from a dynamic orthosis is a feasible tool to enable self-administered practice at home. Such an approach enables practice without dependence on therapist availability, allowing an increase in training dose with respect to treatment in supervised settings. TRIAL REGISTRATION: This study has been registered at the Netherlands Trial Registry (NTR): NTR3669 .

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.

Do Simulated Hospital Admissions Reflect Reality? A Qualitative Study of Volunteer Well-Being During a 24-Hr Simulated Hospitalization.

OBJECTIVES: This study aims to delineate if and how healthy volunteers admitted to simulated care can aid in understanding real well-being experiences of in-hospital surgical patients. BACKGROUND: Scientific research is necessary to understand the mediating effect of healthcare design on patient outcomes. Studies with patients are, however, difficult to conduct as they require substantial funding, time, and research capacity, and recovering patients are often not willing or able to participate. If studies conducted with volunteers provide similar findings, such studies might serve as fruitful alternatives for future research. METHOD: A multimethod study was conducted between July 2017 and December 2017 with 17 volunteers who underwent a 24-hr simulated inpatient postsurgical care protocol. Data on value experiences, norms, and design requirements for an optimal healing environment were collected via diaries and semi-structured value-oriented interviews, focused on the values of spatial comfort, privacy, autonomy, sensory comfort, safety and security, and social comfort. Volunteers' outcomes were compared to prior literature on similar patients' outcomes. RESULTS: Volunteers seem to experience their healing environment similarly to patients with regard to the values of spatial comfort, privacy, autonomy, sensory comfort, and social comfort related to contact with personnel and relatives. Less valuable insights were gained on the values of safety and security, and social comfort related to interaction with other patients, most probably due to the study design and because the participants did not truly experience a diseased bodily state. CONCLUSION: Simulated hospital admissions with volunteers provide a satisfactory alternative for studying real patient outcomes.

Environmental Needs, Barriers, and Facilitators for Optimal Healing in the Postoperative Process: A Qualitative Study of Patients' Lived Experiences and Perceptions.

OBJECTIVES: Gaining an understanding of postoperative patients' environmental needs, barriers, and facilitators for optimal healing. BACKGROUND: An optimal hospital environment (the "healing environment") can enhance patients' postoperative recovery and shorten length of stay. However, insights lack into patients' lived environmental needs for optimal healing after surgery and how these needs are being met. METHOD: A qualitative study was conducted between August 2016 and August 2017 with 21 patients who underwent elective major abdominal surgery in a Dutch university hospital. Data were collected through context-mapping exercises and interviews to capture patients' lived experiences and explore the meaning of these experiences. Data were systematically analyzed according to the principles of thematic content analysis. RESULTS: Three themes were identified. First, participants want a sense of control over their treatment, ambient features, privacy, nutrition, and help requests. Participants described the need for positive distractions: personalizing the room, connecting with the external environment, and the ability to undertake activities. Finally, participants expressed the importance of functional, practical, and emotional support from professionals, peers, and relatives. According to participants, the hospital environment often does not meet their healing needs while being hospitalized. CONCLUSION: The hospital environment often does not meet patients' needs. Needs fulfillment can be improved by practical adjustments to the physical and interpersonal environment and considering patient's individual preferences and changing needs during recovery. Patient narratives, pictures, and drawings are valuable sources for hospital managers in their efforts to design evidence-based environments that anticipate to patient-specific needs for achieving early recovery.

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.

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

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.