Understanding stroke survivors' preferences regarding wearable sensor feedback on functional movement: a mixed-methods study.

BACKGROUND: In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors' preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine the ease of understanding and movement encouragement of feedback based on wearable sensor data (both arm/hand use and mobility) for stroke survivors and to identify preferences for feedback metrics (mode, content, frequency, and timing). METHODS: A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of feedback about arm/hand use, step counts and gait symmetry. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change. RESULTS: Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: (1) Motivation for behavior change, (2) Real-time feedback based on individual goals, and (3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting. CONCLUSION: The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment.

Using a bimanual lever-driven wheelchair for arm movement practice early after stroke: A pilot, randomized, controlled, single-blind trial.

OBJECTIVE: Many patients with subacute stroke rely on the nonparetic arm and leg to propel manual wheelchairs. We designed a bimanual, lever-driven wheelchair (LARA) to promote overground mobility and hemiparetic arm exercise. This study measured the feasibility of using LARA to increase arm movement, achieve mobility, and improve arm motor recovery (clinicaltrials.gov/ct2/show/NCT02830893). DESIGN: Randomized, assessor-blind, controlled trial. SETTING: Two inpatient rehabilitation facilities. SUBJECTS: Nineteen patients with subacute stroke (1 week to 2 months post-stroke) received 30 minutes extra arm movement practice daily, while admitted to inpatient rehabilitation (n = 10) or before enrollment in outpatient therapy (n = 9). INTERVENTIONS: Patients were randomized to train with the LARA wheelchair (n = 11) or conventional exercises with a rehabilitation therapist (n = 8). MAIN MEASURES: Number of arm movements per training session; overground speed; Upper Extremity Fugl-Meyer score at three-month follow-up. RESULTS: Participants who trained with LARA completed 254 (median) arm movements with the paretic arm each session. For three participants, LARA enabled wheelchair mobility at practical indoor speeds (0.15-0.30 m/s). Fugl-Meyer score increased 19 ± 13 points for patients who trained with LARA compared to 14 ± 7 points with conventional exercises (P = 0.32). Secondary measures including shoulder pain and increased tone did not differ between groups. Mixed model analysis found significant interaction between LARA training and treatment duration (P = 0.037), informing power analysis for future investigation. CONCLUSIONS: Practising arm movement with a lever-driven wheelchair is a feasible method for increasing arm movement early after stroke. It enabled wheelchair mobility for a subset of patients and shows potential for improving arm motor recovery.

Design and Evaluation of the Kinect-Wheelchair Interface Controlled (KWIC) Smart Wheelchair for Pediatric Powered Mobility Training.

BACKGROUND: Children with severe disabilities are sometimes unable to access powered mobility training. Thus, we developed the Kinect-Wheelchair Interface Controlled (KWIC) smart wheelchair trainer that converts a manual wheelchair into a powered wheelchair. The KWIC Trainer uses computer vision to create a virtual tether with adaptive shared-control between the wheelchair and a therapist during training. It also includes a mixed-reality video game system. METHODS: We performed a year-long usability study of the KWIC Trainer at a local clinic, soliciting qualitative and quantitative feedback on the device after extended use. RESULTS: Eight therapists used the KWIC Trainer for over 50 hours with 8 different children. Two of the children obtained their own powered wheelchair as a result of the training. The therapists indicated the device allowed them to provide mobility training for more children than would have been possible with a demo wheelchair, and they found use of the device to be as safe as or safer than conventional training. They viewed the shared control algorithm as counter-productive because it made it difficult for the child to discern when he or she was controlling the chair. They were enthusiastic about the video game integration for increasing motivation and engagement during training. They emphasized the need for additional access methods for controlling the device. CONCLUSION: The therapists confirmed that the KWIC Trainer is a useful tool for increasing access to powered mobility training and for engaging children during training sessions. However, some improvements would enhance its applicability for routine clinical use.

Time flies when you are in a groove: using entrainment to mechanical resonance to teach a desired movement distorts the perception of the movement's timing.

The human motor system quickly entrains rhythmic limb movement to the resonant frequency of mechanical systems with which it interacts, suggesting that entrainment to an appropriately designed training device might be a convenient way to teach desired movements. We tested this possibility by asking healthy subjects (N = 30) to learn to move with a desired movement timing using a simple resonating arm training device: a lever attached to a manual wheelchair. The subjects tried to learn to roll the lever-driven wheelchair back and forth in place at a target frequency initially presented using a series of auditory beeps. One-third of the subjects trained without resonance and with no further feedback about rolling frequency; their performance did not improve. Another group trained with continual visual feedback of frequency error but no resonance; they quickly learned to roll the chair at the target frequency, as evidenced at both short-term and long-term (1 day later) retention tests. A third group trained with elastic bands attached to the lever that caused the system to resonate at the target frequency, providing a timing template. While these participants quickly entrained to the target frequency during training, they did not accurately reproduce this frequency when the system was no longer resonant, moving too slowly with the same systematic error at both the short-term and long-term retention tests. They also did not exhibit a timing aftereffect on the initial movements made when they transitioned from a resonant to non-resonant system or vice versa. This suggests they did not realize they were performing the task with a temporal error. Entrainment to mechanical resonance conveys usable information about movement timing, but seems to cause that movement timing to be perceived as slower than it actually is, as if a putative internal clock speeds up, which is a factor to consider in designing machine-assisted motor training.

Wearable Technology to Capture Arm Use of People With Stroke in Home and Community Settings: Feasibility and Early Insights on Motor Performance.

OBJECTIVE: The objectives of this study were to establish the short-term feasibility and usability of wrist-worn wearable sensors for capturing the arm and hand activity of people with stroke and to explore the association between factors related to the use of the paretic arm and hand. METHODS: Thirty people with chronic stroke were monitored with wrist-worn wearable sensors for 12 hours per day for a 7-day period. Participants also completed standardized assessments to capture stroke severity, arm motor impairments, self-perceived arm use, and self-efficacy. The usability of the wearable sensors was assessed using the adapted System Usability Scale and an exit interview. Associations between motor performance and capacity (arm and hand impairments and activity limitations) were assessed using Spearman correlations. RESULTS: Minimal technical issues or lack of adherence to the wearing schedule occurred, with 87.6% of days procuring valid data from both sensors. The average sensor wear time was 12.6 (standard deviation [SD] = 0.2) hours per day. Three participants experienced discomfort with 1 of the wristbands, and 3 other participants had unrelated adverse events. There were positive self-reported usability scores (mean = 85.4/100) and high user satisfaction. Significant correlations were observed for measures of motor capacity and self-efficacy with paretic arm use in the home and the community (Spearman correlation coefficients = 0.44-0.71). CONCLUSIONS: This work demonstrates the feasibility and usability of a consumer-grade wearable sensor for capturing paretic arm activity outside the laboratory. It provides early insight into the everyday arm use of people with stroke and related factors, such as motor capacity and self-efficacy. IMPACT: The integration of wearable technologies into clinical practice offers new possibilities to complement in-person clinical assessments and to better understand how each person is moving outside of therapy and throughout the recovery and reintegration phase. Insight gained from monitoring the arm and hand use of people with stroke in the home and community is the first step toward informing future research with an emphasis on causal mechanisms with clinical relevance.

The IndieTrainer system: a small-scale trial exploring a new approach to support powered mobility skill acquisition in children.

The IndieTrainer system, consisting of a mobility device and video-based gamified training modules, was developed to assist children in attaining power wheelchair (PWC) skills. The purposes of this small-scale trial were to explore the use of the IndieTrainer system to provide PWC skills training and document parental satisfaction with the IndieTrainer system. We hypothesized that PWC skills training provided using the IndieTrainer system would result in improvements in both children's understanding of how to use a PWC and their PWC skill execution, and that parental satisfaction would be high. An open-label, single-arm trial was conduct as follows: (a) Baseline testing (T0); (b) A 3-week intervention consisting of two, 60-min-PWC skills training sessions per week; (c) Post-intervention testing (T1); and (d) A single session retention trial held 4 weeks after completion of the intervention (T2). Outcome measures included the Assessment of Learning Powered mobility use (ALP), Wheelchair Skills Checklist (WSC), Canadian Occupational Performance Measure (COPM), and Client Satisfaction Questionnaire-8 (CSQ-8). 25 child/parent dyads participated. Between T0 and T1, statistically significant differences (p-value <.0001) with large effect sizes in mean ALP and WSC scores (ALP: d = 3.14; WSC: d = 3.25) and COPM performance and satisfaction scores (Performance: d = 4.66; Satisfaction: d = 3.24) were achieved. Mean T1 total CSQ-8 score was 31.52/32. At T2, all children maintained or improved their T1 ALP and WSC scores. This study provides initial support for the usability and feasibility of the IndieTrainer system. Futhermore, larger scaled studies using more rigorous research designs are indicated.

The IndieTrainer system allows clinicians to tailor power wheelchair skills (PWC) skills training based on an individual child's specific goals and level of understanding.Selectively combining the use of progressive video-based gamified modules and real-world power mobility experiences may support children who are learning PWC skills.When provided with progressive PWC skills training, children with severe disabilities may improve their understanding of how to use a PWC and their PWC skills.

Using Large-Scale Sensor Data to Test Factors Predictive of Perseverance in Home Movement Rehabilitation: Early Exercise Frequency and Schedule Consistency.

Home-based exercises are an important component of stroke rehabilitation but are seldom fully completed. Past studies of exercise perseverance in the general public have suggested the importance of early exercise frequency and schedule consistency (in terms of which days of the week exercises are performed) because they encourage habit formation. To test whether these observations apply after a stroke, we leveraged data from 2,583 users of a sensor-based system (FitMi) developed to motivate movement exercises at home. We grouped users based on their early exercise frequency (defined across the initial 6 weeks of use) and calculated the evolution of habit score (defined as exercise frequency multiplied by exercise duration) across 6 months. We found that habit score decayed exponentially over time but with a slower decay constant for individuals with higher early frequency. Only the group with an early exercise frequency of 4 days/week or more had non-zero habit score at six months. Within each frequency group, dividing individuals into higher and lower consistency subgroups revealed that the higher consistency subgroups had significantly higher habit scores. These results are consistent with previous studies on habit formation in exercise and may help in designing effective home rehabilitation programs after stroke.

The Resonating Arm Exerciser: design and pilot testing of a mechanically passive rehabilitation device that mimics robotic active assistance.

BACKGROUND: Robotic arm therapy devices that incorporate actuated assistance can enhance arm recovery, motivate patients to practice, and allow therapists to deliver semi-autonomous training. However, because such devices are often complex and actively apply forces, they have not achieved widespread use in rehabilitation clinics or at home. This paper describes the design and pilot testing of a simple, mechanically passive device that provides robot-like assistance for active arm training using the principle of mechanical resonance. METHODS: The Resonating Arm Exerciser (RAE) consists of a lever that attaches to the push rim of a wheelchair, a forearm support, and an elastic band that stores energy. Patients push and pull on the lever to roll the wheelchair back and forth by about 20 cm around a neutral position. We performed two separate pilot studies of the device. In the first, we tested whether the predicted resonant properties of RAE amplified a user's arm mobility by comparing his or her active range of motion (AROM) in the device achieved during a single, sustained push and pull to the AROM achieved during rocking. In a second pilot study designed to test the therapeutic potential of the device, eight participants with chronic stroke (35 ± 24 months since injury) and a mean, stable, initial upper extremity Fugl-Meyer (FM) score of 17 ± 8 / 66 exercised with RAE for eight 45 minute sessions over three weeks. The primary outcome measure was the average AROM measured with a tilt sensor during a one minute test, and the secondary outcome measures were the FM score and the visual analog scale for arm pain. RESULTS: In the first pilot study, we found people with a severe motor impairment after stroke intuitively found the resonant frequency of the chair, and the mechanical resonance of RAE amplified their arm AROM by a factor of about 2. In the second pilot study, AROM increased by 66% ± 20% (p = 0.003). The mean FM score increase was 8.5 ± 4 pts (p = 0.009). Subjects did not report discomfort or an increase in arm pain with rocking. Improvements were sustained at three months. CONCLUSIONS: These results demonstrate that a simple mechanical device that snaps onto a manual wheelchair can use resonance to assist arm training, and that such training shows potential for safely increasing arm movement ability for people with severe chronic hemiparetic stroke.

Understanding Characteristics of User Adherence to Optimize the Use of Home Hand Rehabilitation Technology.

Home-based rehabilitation can serve as an adjunct to in-clinic rehabilitation, encouraging users to engage in more practice. However, conventional home-based rehabilitation programs suffer from low adherence and high drop-out rates. Wearable movement sensors coupled with computer games can be more engaging, but have highly variable adherence rates. Here we examined characteristics of user adherence by analyzing unsupervised, wearable grip sensor-based home-hand rehabilitation data from 1,587 users. We defined three different classes of users based on activity level: low users (<2 days), medium users (2 - 9 days), and power users (> 9 days). The probability of using the device more than two days was positively correlated with first day game success (p = 0.91, p<. 001), and number of sessions played on the first day (p = 0.87, p<. 001) but negatively correlated with parameter exploration (total number of game adjustments / total number of sessions played) on the first day (p = - 0.31, p= 0.05). Compared to low users, power users on the first day had more game success (65.18 ± 25.76 %vs. 54.94 ± 30.31 %,p <. 001), parameter exploration (25.47 ± 22.78 % vs. 12.05 ± 20.56 %, p <. 001), and game sessions played (7.60 ± 6.59 sessions vs. 4.04 ± 3.56 sessions, p <. 001). These observations support the premise that initial game success which is modulated by strategically adjusting parameters when necessary is a key determinant of adherence to rehabilitation technology.

The IndieTrainer system: a clinical trial protocol exploring use of a powered wheelchair training intervention for children with cerebral palsy.

OBJECTIVE: The IndieTrainer system, comprised of both a mobility device and gamified training modules, was developed to aid powered wheelchair (PWC) skills acquisition in children with cerebral palsy (CP). The aims of this small-scale study are to: explore use of the IndieTrainer system to improve PWC skills in children who have CP and document parental/caregiver perceptions of, and satisfaction with, the IndieTrainer system. METHOD: This small-scale study is an open-label single-arm clinical trial involving a three-week PWC training intervention consisting of two 60-minute training sessions per week. A single session retention trial will be held four weeks after the completion of the intervention period. All research activities will take place in-person in a laboratory-based setting located within a university. Twenty-five child-parent/caregiver dyads will participate in the study. Each child participant will be 3 to 21 years of age and have a diagnosis of CP or other similar condition. The Assessment of Learning Powered mobility use will be the primary outcome measure. Secondary outcome measures will include the Wheelchair Skills Checklist, the Canadian Occupational Performance Measure, the Customer Satisfaction Questionnaire-8, and a qualitative interview. Data analyses will involve one-way repeated measures ANOVAs followed by paired samples t-tests with Bonferroni adjustments. IMPACT: The IndieTrainer system allows children to explore and use power mobility in their own manual wheelchair and was designed to meet the needs of power mobility learners across the continuum of learning. It is the first PWC training system to optimize learning for early learners who do not yet understand cause and effect concepts.IMPLICATIONS FOR REHABILITATIONThe IndieTrainer system is designed to meet the needs of power mobility learners across the continuum of learning.This protocol outlines a novel means of providing progressive power mobility training.The IndieTrainer was designed to expand power mobility access to children with cerebral palsy, a previously underserved population.

Exercise repetition rate measured with simple sensors at home can be used to estimate Upper Extremity Fugl-Meyer score after stroke.

Introduction: It would be valuable if home-based rehabilitation training technologies could automatically assess arm impairment after stroke. Here, we tested whether a simple measure-the repetition rate (or "rep rate") when performing specific exercises as measured with simple sensors-can be used to estimate Upper Extremity Fugl-Meyer (UEFM) score. Methods: 41 individuals with arm impairment after stroke performed 12 sensor-guided exercises under therapist supervision using a commercial sensor system comprised of two pucks that use force and motion sensing to measure the start and end of each exercise repetition. 14 of these participants then used the system at home for three weeks. Results: Using linear regression, UEFM score was well estimated using the rep rate of one forward-reaching exercise from the set of 12 exercises (r2 = 0.75); this exercise required participants to alternately tap pucks spaced about 20 cm apart (one proximal, one distal) on a table in front of them. UEFM score was even better predicted using an exponential model and forward-reaching rep rate (Leave One Out Cross Validation (LOOCV) r2 = 0.83). We also tested the ability of a nonlinear, multivariate model (a regression tree) to predict UEFM, but such a model did not improve prediction (LOOCV r2 = 0.72). However, the optimal decision tree also used the forward-reaching task along with a pinch grip task to subdivide more and less impaired patients in a way consistent with clinical intuition. At home, rep rate for the forward-reaching exercise well predicted UEFM score using an exponential model (LOOCV r2 = 0.69), but only after we re-estimated coefficients using the home data. Discussion: These results show how a simple measure-exercise rep rate measured with simple sensors-can be used to infer an arm impairment score and suggest that prediction models should be tuned separately for the clinic and home environments.

Optimized Home Rehabilitation Technology Reduces Upper Extremity Impairment Compared to a Conventional Home Exercise Program: A Randomized, Controlled, Single-Blind Trial in Subacute Stroke.

BACKGROUND: Upper extremity (UE) stroke rehabilitation requires patients to perform exercises at home, yet patients show limited benefit from paper-based home exercise programs. OBJECTIVE: To compare the effectiveness of 2 home exercise programs for reducing UE impairment: a paper-based approach and a sensorized exercise system that incorporates recommended design features for home rehabilitation technology. METHODS: In this single-blind, randomized controlled trial, 27 participants in the subacute phase of stroke were assigned to the sensorized exercise (n = 14) or conventional therapy group (n = 13), though 2 participants in the conventional therapy group were lost to follow-up. Participants were instructed to perform self-guided movement training at home for at least 3 hours/week for 3 consecutive weeks. The sensorized exercise group used FitMi, a computer game with 2 puck-like sensors that encourages movement intensity and auto-progresses users through 40 exercises. The conventional group used a paper book of exercises. The primary outcome measure was the change in Upper Extremity Fugl-Meyer (UEFM) score from baseline to follow-up. Secondary measures included the Modified Ashworth Scale for spasticity (MAS) and the Visual Analog Pain (VAP) scale. RESULTS: Participants who used FitMi improved by an average of 8.0 ± 4.6 points on the UEFM scale compared to 3.0 ± 6.1 points for the conventional participants, a significant difference (t-test, P = .029). FitMi participants exhibited no significant changes in UE MAS or VAP scores. CONCLUSIONS: A sensor-based exercise system incorporating a suite of recommended design features significantly and safely reduced UE impairment compared to a paper-based, home exercise program. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT03503617.

A Dynamic Wheelchair Armrest for Promoting Arm Exercise and Mobility After Stroke.

Arm movement recovery after stroke can improve with sufficient exercise. However, rehabilitation therapy sessions are typically not enough. To address the need for effective methods of increasing arm exercise outside therapy sessions we developed a novel armrest, called Boost. It easily attaches to a standard manual wheelchair just like a conventional armrest and enables users to exercise their arm in a linear forward-back motion. This paper provides a detailed design description of Boost, the biomechanical analysis method to evaluate the joint torques required to operate it, and the results of pilot testing with five stroke patients. Biomechanics results show the required shoulder flexion and elbow extension torques range from -25% to +36% of the torques required to propel a standard pushrim wheelchair, depending on the direction of applied force. In pilot testing, all five participants were able to exercise the arm with Boost in stationary mode (with lower physical demand). Three achieved overground ambulation (with higher physical demand) exceeding 2 m/s after 2-5 practice trials; two of these could not propel their wheelchair with the pushrim. This simple to use, dynamic armrest provides people with hemiparesis a way to access repetitive arm exercise outside of therapy sessions, independently right in their wheelchair. Significantly, Boost removes the requirements to reach, grip, and release the pushrim to propel a wheelchair, an action many individuals with stroke cannot complete.

Using Large-Scale Sensor Data to Test Factors Predictive of Perseverance in Home Movement Rehabilitation: Optimal Challenge and Steady Engagement.

Persevering with home rehabilitation exercise is a struggle for millions of people in the US each year. A key factor that may influence motivation to engage with rehabilitation exercise is the challenge level of the assigned exercises, but this hypothesis is currently supported only by subjective, self-report. Here, we studied the relationship between challenge level and perseverance using long-term, self-determined exercise patterns of a large number of individuals (N = 2,581) engaging in home rehabilitation with a sensor-based exercise system without formal supervision. FitMi is comprised of two puck-like sensors and a library of 40 gamified exercises for the hands, arms, trunk, and legs that are designed for people recovering from a stroke. We found that individuals showed the greatest perseverance with the system over a 2-month period if they had (1) a moderate level of motor impairment and (2) high but not perfect success during the 1st week at completing the exercise game. Further, a steady usage pattern (vs. accelerating or decelerating use) was associated with more overall exercise, and declines in exercise amount over time were associated with exponentially declining session initiation probability rather than decreasing amounts of exercise once a session was initiated. These findings confirm that an optimized challenge level and regular initiation of exercise sessions predict achievement of a greater amount of overall rehabilitation exercise in a group of users of commercial home rehabilitation technology and suggest how home rehabilitation programs and exercise technologies can be optimized to promote perseverance.

Bimanual wheelchair propulsion by people with severe hemiparesis after stroke.

PURPOSE: Individuals who require manual wheelchairs after stroke are typically taught to ambulate with compensatory propulsion (i.e., using their non-paretic arm and foot), risking disuse of the paretic arm. We investigated whether stroke survivors can instead ambulate in a bimanual, lever-driven wheelchair that requires the paretic arm to contribute half the propulsive input. MATERIALS AND METHODS: Seventeen individuals with chronic stroke and severe hemiparesis (upper extremity Fugl-Meyer scores between 10 and 24) participated across two experiments. In the first experiment, participants (n = 12) ambulated in straight paths. In the second experiment, participants (n = 12) also performed turns, using an improved version of the wheelchair that incorporated handbrakes. Twelve unimpaired controls also completed the second experiment. Motion capture and EMG were used to compare biomechanics between groups. RESULTS: Altogether, 15 of 17 participants with stroke could ambulate 30 m in straight paths, and 9 of 12 could turn 1800° entirely under the power of their paretic arm. Participants with stroke exhibited largely healthy biomechanics, with minimal shoulder hiking/leaning or trunk inclination. Their arm muscle EMG patterns were similar to those used by unimpaired participants, excepting delayed elbow extensor activation. CONCLUSIONS: Individuals with severe arm impairment in the chronic stage of stroke retain sufficient strength and coordination with their paretic arm to manoeuvre bimanual, lever-driven wheelchairs. We suggest bimanual, lever-driven propulsion should be explored in stroke rehabilitation practice as an alternative to compensatory wheelchair propulsion, as it has the potential to exercise healthy movement synergies, which may in turn help drive use-dependent motor recovery. Implications for rehabilitation Severe arm impairment arising after stroke does not generally eliminate the motor dexterity needed to bimanually propel a manual wheelchair, provided that the wheelchair is modified to remove the requirement to grasp and release the push rim. Such exercise appears a good candidate to facilitate rehabilitation outcomes because it depends on alternating muscle activity and improving elbow extension. Such wheelchair propulsion involves largely normal biomechanics; shoulder hiking and leaning are absent and trunk inclination is rare.

A Pilot Study of a Sensor Enhanced Activity Management System for Promoting Home Rehabilitation Exercise Performed during the COVID-19 Pandemic: Therapist Experience, Reimbursement, and Recommendations for Implementation.

Adherence to home exercise programs (HEPs) during physical rehabilitation is usually unmonitored and is thought to be low from self-reports. This article describes exploratory implementation of a Sensor Enhanced Activity Management (SEAM) system that combines HEP management software with a movement sensor for monitoring and motivating HEP adherence. The article also presents results from attempting to gain reimbursement for home use of the system with therapist oversight using Remote Physiologic Monitoring (RPM) codes. Four therapists used the system in their regular practice during the first six months of the COVID-19 pandemic. Therapists filled out surveys, kept notes, and participated in interviews. Billing and reimbursement data were obtained from the treatment facility. Exercise data from the SEAM system were used to understand HEP adherence. Patients were active for a mean of 40% (26% SD) of prescribed days and completed a mean of 25% (25% SD) of prescribed exercises. The therapists billed 23 RPM codes (USD 2353), and payers reimbursed eight of those instances (USD 649.21). The therapists reported that remote monitoring and the use of a physical movement sensor was motivating to their patients and increased adherence. Sustained technical support for therapists will likely improve implementation of new remote monitoring and treatment systems. RPM codes may enable reimbursement for review and program management activities, but, despite COVID-19 CMS waivers, organizations may have more success if these services are billed under supervision of a physician.

Home-based hand rehabilitation after chronic stroke: Randomized, controlled single-blind trial comparing the MusicGlove with a conventional exercise program.

UNLABELLED: Individuals with chronic stroke have limited options for hand rehabilitation at home. Here, we sought to determine the feasibility and efficacy of home-based MusicGlove therapy. Seventeen participants with moderate hand impairment in the chronic phase of stroke were randomized to 3 wk of home-based exercise with either the MusicGlove or conventional tabletop exercises. The primary outcome measure was the change in the Box and Blocks test score from baseline to 1 mo posttreatment. Both groups significantly improved their Box and Blocks test score, but no significant difference was found between groups. The MusicGlove group did exhibit significantly greater improvements than the conventional exercise group in motor activity log quality of movement and amount of use scores 1 mo posttherapy (p = 0.007 and p = 0.04, respectively). Participants significantly increased their use of MusicGlove over time, completing 466 gripping movements per day on average at study end. MusicGlove therapy was not superior to conventional tabletop exercises for the primary end point but was nevertheless feasible and led to a significantly greater increase in self-reported functional use and quality of movement of the impaired hand than conventional home exercises. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; "Influence of Timing on Motor Learning"; NCT01769326; https://clinicaltrials.gov/ct2/show/NCT01769326.

Machine-Based, Self-guided Home Therapy for Individuals With Severe Arm Impairment After Stroke: A Randomized Controlled Trial.

BACKGROUND: Few therapeutic options exist for the millions of persons living with severe arm impairment after stroke to increase their dose of arm rehabilitation. This study compared self-guided, high-repetition home therapy with a mechanical device (the resonating arm exerciser [RAE]) to conventional therapy in patients with chronic stroke and explored RAE use for patients with subacute stroke. METHODS: A total of 16 participants with severe upper-extremity impairment (mean Fugl-Meyer [FM] score = 21.4 ± 8.8 out of 66) >6 months poststroke were randomized to 3 weeks of exercise with the RAE or conventional exercises. The primary outcome measure was FM score 1 month posttherapy. Secondary outcome measures included Motor Activity Log, Visual Analog Pain Scale, and Ashworth Spasticity Scale. After a 1-month break, individuals in the conventional group also received a 3-week course of RAE therapy. RESULTS: The change in FM score was significant in both the RAE and conventional groups after training (2.6 ± 1.4 and 3.4 ± 2.4, P = .008 and .016, respectively). These improvements were not significant at 1 month. Exercise with the RAE led to significantly greater improvements in distal FM score than conventional therapy at the 1-month follow-up (P = .02). In a separate cohort of patients with subacute stroke, the RAE was found feasible for exercise. DISCUSSION: In those with severe arm impairment after chronic stroke, home-based training with the RAE was feasible and significantly reduced impairment without increasing pain or spasticity. Gains with the RAE were comparable to those found with conventional training and also included distal arm improvement.

Feasibility of a bimanual, lever-driven wheelchair for people with severe arm impairment after stroke.

Individuals with severe arm impairment after stroke are thought to be unable to use a manual wheelchair in the conventional bimanual fashion, because they cannot grip and push the pushrim with their impaired hand. Instead, they are often taught to propel a wheelchair with their good arm and leg, a compensatory strategy that encourages disuse and may cause asymmetric tone. Here, we show that four stroke survivors (9, 27 50 and 16 months post stroke) with severe arm impairment (upper extremity Fugl Meyer scores of 21, 17, 16 and 15 of 66 respectively) were able to propel themselves overground during ten, 3.3 meter movement trials, using a specially designed lever-driven wheelchair adapted with a splint and elastic bands. Their average speed on the tenth trial was about 0.1 m/sec. These results suggest that individuals with stroke could use bimanual wheelchair propulsion for mobility, both avoiding the problems associated with good-arm/good-leg propulsion and increasing the number of daily arm movements they achieve, which may improve arm movement recovery.

Lever-actuated resonance assistance (LARA): a wheelchair-based method for upper extremity therapy and overground ambulation for people with severe arm impairment.

People with severe arm impairment have limited technologies available for retraining their arms, and, if they also have difficulty walking, they often cannot effectively use a manual wheelchair because they cannot grasp and push the pushrim. We are using Lever-Actuated Resonance Assistance (LARA) to solve these problems. A LARA-based device can attach to a manual wheelchair and allow it to be used by people with severe arm weakness in a stationary exercise mode, or for self-powered overground ambulation. LARA uses a lever drive and arm support to appropriately position the arm and to reduce the dexterity required to operate the wheelchair. It also uses mechanical resonance implemented with elastic bands to provide assistance for both stationary exercise and overground ambulation. We first review here pilot results in which we used the LARA method to provide arm therapy to individuals with chronic stroke in stationary exercise mode. We then describe a novel motion-based user interface that allows individuals to control a video game with LARA while operating a wheelchair in resonance. Finally, for overground ambulation mode, we show in simulation that the mechanical resonance provided by LARA theoretically allows people with severe arm weakness to propel themselves with reduced effort and obtain speeds previously unattainable.