Clinician perceptions of a novel wearable robotic hand orthosis for post-stroke hemiparesis.

PURPOSE: Wearable robotic devices are currently being developed to improve upper limb function for individuals with hemiparesis after stroke. Incorporating the views of clinicians during the development of new technologies can help ensure that end products meet clinical needs and can be adopted for patient care. METHODS: In this cross-sectional mixed-methods study, an anonymous online survey was used to gather clinicians' perceptions of a wearable robotic hand orthosis for post-stroke hemiparesis. Participants were asked about their clinical experience and provided feedback on the prototype device after viewing a video. RESULTS: 154 participants completed the survey. Only 18.8% had previous experience with robotic technology. The majority of participants (64.9%) reported that they would use the device for both rehabilitative and assistive purposes. Participants perceived that the device could be used in supervised clinical settings with all phases of stroke. Participants also indicated a need for insurance coverage and quick setup time. CONCLUSIONS: Engaging clinicians early in the design process can help guide the development of wearable robotic devices. Both rehabilitative and assistive functions are valued by clinicians and should be considered during device development. Future research is needed to understand a broader set of stakeholders' perspectives on utility and design.

Clinicians valued both assistive and rehabilitative uses of a wearable robotic hand orthosis designed for individuals with hemiparesis after stroke.Wearable robotic hand devices should have the capacity to engage in functional, real-world activities for both assistive and rehabilitative purposes.Pragmatic factors, such as set-up and training time, must be balanced with device complexity to enable implementation in clinical settings.Stakeholders, such as clinicians, play an important role in identifying design priorities for wearable robotic devices to ensure these devices can meet the needs of end-users.

Motor Learning Following Stroke: Mechanisms of Learning and Techniques to Augment Neuroplasticity.

Sensorimotor impairments are common after stroke requiring stroke survivors to relearn lost motor skills or acquire new ones in order to engage in daily activities. Thus, motor skill learning is a cornerstone of stroke rehabilitation. This article provides an overview of motor control and learning theories that inform stroke rehabilitation interventions, discusses principles of neuroplasticity, and provides a summary of practice conditions and techniques that can be used to augment motor learning and neuroplasticity in stroke rehabilitation.

A Call to Shift to Competency-Based Education.

This column explores the concept of competency-based education (CBE). A shift to CBE is a key trend for the future of health care education. Health care professions that have adopted, or started to adopt, a CBE framework include physical therapy, speech-language pathology, social work, medicine, nursing, pharmacology, and dentistry. Internationally, many occupational therapy programs are in the process of shifting to, or have shifted to, a CBE model. This column discusses how although select occupational therapy programs in the United States may individually be considering shifting to, or have shifted to, a CBE framework, there is no national movement to explore adopting the model for occupational therapy or a consensus on defined outcomes for the profession.

Data-Driven Quantitation of Movement Abnormality after Stroke.

Stroke commonly affects the ability of the upper extremities (UEs) to move normally. In clinical settings, identifying and measuring movement abnormality is challenging due to the imprecision and impracticality of available assessments. These challenges interfere with therapeutic tracking, communication, and treatment. We thus sought to develop an approach that blends precision and pragmatism, combining high-dimensional motion capture with out-of-distribution (OOD) detection. We used an array of wearable inertial measurement units to capture upper body motion in healthy and chronic stroke subjects performing a semi-structured, unconstrained 3D tabletop task. After data were labeled by human coders, we trained two deep learning models exclusively on healthy subject data to classify elemental movements (functional primitives). We tested these healthy subject-trained models on previously unseen healthy and stroke motion data. We found that model confidence, indexed by prediction probabilities, was generally high for healthy test data but significantly dropped when encountering OOD stroke data. Prediction probabilities worsened with more severe motor impairment categories and were directly correlated with individual impairment scores. Data inputs from the paretic UE, rather than trunk, most strongly influenced model confidence. We demonstrate for the first time that using OOD detection with high-dimensional motion data can reveal clinically meaningful movement abnormality in subjects with chronic stroke.

Effectiveness of Occupational Therapy Interventions to Improve Performance and Participation in Instrumental Activities of Daily Living (IADL) Among Adult Stroke Survivors (2009-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme and/or subthemes, related to a specific topic. This Systematic Review Brief summarizes findings from the systematic review on interventions to improve performance and participation in instrumental activities of daily living among adult stroke survivors. This theme reports on the effectiveness of virtual reality, exercise, vision rehabilitation, and community-based stroke empowerment group interventions.

Occupational Therapy and Activities of Daily Living Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for occupational therapy and activities of daily living (ADL) interventions to improve ADL outcomes for adults with stroke.

Effectiveness of Task-Oriented Approaches and Occupation-Based Activities to Improve Performance and Participation in Instrumental Activities of Daily Living (IADL) Among Adult Stroke Survivors (2009-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for task-oriented/occupation-based approaches and augmenting task-oriented training with cognitive strategies to support performance in instrumental activities of daily living among adult stroke survivors.

Preparatory Interventions to Support ADL Performance for Adults With Stroke (2012-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for preparatory interventions to support performance in activities of daily living for adults with stroke, such as early mobilization, bilateral priming, passive range of motion, sensory retraining, and shoulder taping.

Task-Oriented Training With Cognitive Strategies for Adults With Stroke to Improve ADL and/or Functional Mobility Performance (2012-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on interventions to improve activities of daily living and functional mobility performance for people with stroke. This theme reports on task-oriented training with cognitive strategies.

Technology-Related Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for technology-related interventions to improve performance in activities of daily living for adults with stroke, such as virtual reality/gaming, biofeedback, robotics, electrical stimulation, and telerehabilitation.

Behavioral Interventions to Improve Performance in Activities of Daily Living for Adults With Stroke (2012-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings for behavioral interventions to improve outcomes in activities of daily living for adults with stroke, including cognitive, self-management, falls prevention, psychosocial, and creative/recreation interventions.

Task Oriented Training Interventions for Adults With Stroke to Improve ADL and Functional Mobility Performance (2012-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on interventions to improve activities of daily living (ADL) and functional mobility performance for people with stroke. This theme reports on task-oriented training interventions.

Exercise for Adults With Stroke to Improve ADL and/or Functional Mobility Performance (2012-2019).

Systematic Review Briefs provide a summary of the findings from systematic reviews developed in conjunction with the American Occupational Therapy Association's Evidence-Based Practice Program. Each Systematic Review Brief summarizes the evidence on a theme related to a systematic review topic. This Systematic Review Brief presents findings from the systematic review on interventions to improve activities of daily living (ADL) and functional mobility performance for people with stroke. This theme reports on exercise interventions.

Dual-Tasking in Daily Activities Among Adults With and Without Stroke.

IMPORTANCE: In laboratory settings, dual-tasking is a performance strategy affected by dominance and stroke. However, the volitional use of dual-tasking has not been examined during naturalistic performance of activities of daily living (ADLs). OBJECTIVE: To examine dual-tasking in the context of ADLs and identify whether dominance and stroke influence its use. DESIGN: Cross-sectional, observational. SETTING: Academic medical center. PARTICIPANTS: Forty-three participants with chronic stroke and upper extremity (UE) motor impairment and 19 control participants without stroke. OUTCOMES AND MEASURES: We identified dual-tasking as the performance of dual-object primitives (DOPs), a functional strategy to manage two objects simultaneously. We videotaped participants performing feeding and toothbrushing tasks and identified the initiation and frequency of DOPs. We assessed whether these outcomes were influenced by UE dominance or paresis and whether among participants with stroke these outcomes were influenced by motor impairment (using the Fugl-Meyer Assessment) or cognitive impairment (using the Montreal Cognitive Assessment). RESULTS: DOP initiation was reduced on the nondominant side of control UEs and in the paretic UE of participants with stroke. After DOPs were initiated, however, their frequency was not significantly related to dominance or paresis. Among participants with stroke, DOP initiation but not DOP frequency was influenced by motor impairment, and neither were influenced by cognitive impairment. CONCLUSIONS AND RELEVANCE: The initiation of dual-tasking is curtailed in the nondominant and paretic UEs, extending previous laboratory-based findings to a more naturalistic setting. These results may reflect a demand on neural resources that is exceeded when these limbs are used. What This Article Adds: DOPs, a functional strategy to simultaneously engage two objects during ADLs, could serve as a behavioral marker of dual-tasking in real-world activities, supporting their investigation more broadly. Practicing DOPs in rehabilitation could also train the integration of dual-tasking strategies in activity execution.

PrimSeq: A deep learning-based pipeline to quantitate rehabilitation training.

Stroke rehabilitation seeks to accelerate motor recovery by training functional activities, but may have minimal impact because of insufficient training doses. In animals, training hundreds of functional motions in the first weeks after stroke can substantially boost upper extremity recovery. The optimal quantity of functional motions to boost recovery in humans is currently unknown, however, because no practical tools exist to measure them during rehabilitation training. Here, we present PrimSeq, a pipeline to classify and count functional motions trained in stroke rehabilitation. Our approach integrates wearable sensors to capture upper-body motion, a deep learning model to predict motion sequences, and an algorithm to tally motions. The trained model accurately decomposes rehabilitation activities into elemental functional motions, outperforming competitive machine learning methods. PrimSeq furthermore quantifies these motions at a fraction of the time and labor costs of human experts. We demonstrate the capabilities of PrimSeq in previously unseen stroke patients with a range of upper extremity motor impairment. We expect that our methodological advances will support the rigorous measurement required for quantitative dosing trials in stroke rehabilitation.

Design of Spiral-Cable Forearm Exoskeleton to Assist Supination for Hemiparetic Stroke Subjects.

We present the development of a cable-based passive forearm exoskeleton that is designed to assist supination for hemiparetic stroke survivors. Our device uniquely provides torque sufficient for counteracting spasticity within a below-elbow apparatus. The mechanism consists of a spiral single-tendon routing embedded in a rigid forearm brace and terminated at the hand and upper-forearm. A spool with an internal releasable-ratchet mechanism allows the user to manually retract the tendon and rotate the hand to counteract involuntary pronation synergies due to stroke. We characterize the mechanism with benchtop testing and five healthy subjects, and perform a preliminary assessment of the exoskeleton with a single chronic stroke subject having minimal supination ability. The mechanism can be integrated into an existing active hand-opening orthosis to enable supination support during grasping tasks, and also allows for a future actuated supination strategy.

Assessing and Building Clinical Competence in Occupational Therapists Treating Patients with Neurodegenerative Disease: A Community of Practice Study.

Communities of practice (CoPs) can be an effective means by which to efficiently build skills, knowledge, and competence for occupational therapists. The objective of this study was to assess changes in clinical competence for occupational therapists treating patients with neurodegenerative diseases (NDD) after participating in a CoP. A cohort of home health occupational therapists was recruited to participate in a seven-week CoP focused on treating patients with NDD. A single group pretest posttest mixed methods design was used to measure changes in clinical competence of the participants through a validated self-report assessment tool and a qualitative analysis of treatment summaries. Thirteen occupational therapists participated in the study. There were significant changes in pretest and post-test knowledge, beliefs, and action scores, indicating a positive change in the participants' competence to treat patients with NDD. Qualitative findings support positive changes in clinical competence through increased knowledge, confidence, and use of interventions aimed at optimizing occupational performance for this population. In summary, the CoP was an effective method for building clinical competence for treating patients with NDD with this cohort of occupational therapists.

Thumb Stabilization and Assistance in a Robotic Hand Orthosis for Post-Stroke Hemiparesis.

We propose a dual-cable method of stabilizing the thumb in the context of a hand orthosis designed for individuals with upper extremity hemiparesis after stroke. This cable network adds opposition/reposition capabilities to the thumb, and increases the likelihood of forming a hand pose that can successfully manipulate objects. In addition to a passive-thumb version (where both cables are of fixed length), our approach also allows for a single-actuator active-thumb version (where the extension cable is actuated while the abductor remains passive), which allows a range of motion intended to facilitate creating and maintaining grasps. We performed experiments with five chronic stroke survivors consisting of unimanual resistive-pull tasks and bimanual twisting tasks with simulated real-world objects; these explored the effects of thumb assistance on grasp stability and functional range of motion. Our results show that both active- and passive-thumb versions achieved similar performance in terms of improving grasp force generation over a no-device baseline, but active thumb stabilization enabled users to maintain grasps for longer durations.

Adaptive Semi-Supervised Intent Inferral to Control a Powered Hand Orthosis for Stroke.

In order to provide therapy in a functional context, controls for wearable robotic orthoses need to be robust and intuitive. We have previously introduced an intuitive, user-driven, EMG-based method to operate a robotic hand orthosis, but the process of training a control that is robust to concept drift (changes in the input signal) places a substantial burden on the user. In this paper, we explore semi-supervised learning as a paradigm for controlling a powered hand orthosis for stroke subjects. To the best of our knowledge, this is the first use of semi-supervised learning for an orthotic application. Specifically, we propose a disagreement-based semi-supervision algorithm for handling intrasession concept drift based on multimodal ipsilateral sensing. We evaluate the performance of our algorithm on data collected from five stroke subjects. Our results show that the proposed algorithm helps the device adapt to intrasession drift using unlabeled data and reduces the training burden placed on the user. We also validate the feasibility of our proposed algorithm with a functional task; in these experiments, two subjects successfully completed multiple instances of a pick-and-handover task.

Home mirror therapy: a randomized controlled pilot study comparing unimanual and bimanual mirror therapy for improved arm and hand function post-stroke.

PURPOSE: To compare home-based unimanual mirror therapy (UMT) and bimanual mirror therapy (BMT) for upper limb recovery in subacute/chronic stroke individuals with moderate-to-severe arm impairment. METHOD: Twenty-two participants were randomized into 1 of 3 groups: UMT, BMT or traditional occupational therapy (TOT) home-based programs. The intervention was 6-weeks and consisted of OT 2 days a week, weekly sessions with the research OT, and 30-minutes of the home-based program 5 days a week, according to group allocation. The Action Research Arm Test (ARAT), ABILHAND, Fugl-Meyer Assessment (FMA), grip strength, and Stroke Impact Scale (SIS) were used for outcome measures. RESULTS: All groups significantly improved over time on all outcome measures and adhered to the prescribed dosage regardless of group (p<0.05). While there were no between-group differences, effect size and 95% confidence interval data suggest a clinical significance in favor of UMT as compared to the other groups. CONCLUSIONS: All participants, regardless of home-based program, adhered to the prescribed dosage and significantly improved over time. Despite no between-group differences, effect size and 95% confidence interval data suggest that UMT may be more beneficial for individuals with moderate-to-severe arm impairment as compared to BMT or TOT. ClinicalTrials.gov: #NCT02780440Implications for RehabilitationHome-based unimanual mirror therapy (UMT), bimanual mirror therapy (BMT), and traditional occupational therapy (TOT), when administered in conjunction with outpatient OT, are helpful for improving upper limb recovery post-stroke.Home-based UMT may be more beneficial than BMT or TOT for improvement in upper limb motor function and activities of daily living of patients with moderate to severe arm impairment post-stroke.