Utility and usability of a wearable system and progressive-challenge cued exercise program for encouraging use of the more involved arm at-home after stroke-a feasibility study with case reports.

BACKGROUND: Understanding the role of adherence to home exercise programs for survivors of stroke is critical to ensure patients perform prescribed exercises and maximize effectiveness of recovery. METHODS: Survivors of hemiparetic stroke with impaired motor function were recruited into a 7-day study designed to test the utility and usability of a low-cost wearable system and progressive-challenge cued exercise program for encouraging graded-challenge exercise at-home. The wearable system comprised two wrist-worn MetaMotionR+ activity monitors and a custom smartphone app. The progressive-challenge cued exercise program included high-intensity activities (one repetition every 30 s) dosed at 1.5 h per day, embedded within 8 h of passive activity monitoring per day. Utility was assessed using measures of system uptime and cue response rate. Usability and user experience were assessed using well-validated quantitative surveys of system usability and user experience. Self-efficacy was assessed at the end of each day on a visual analog scale that ranged from 0 to 100. RESULTS: The system and exercise program had objective utility: system uptime was 92 ± 6.9% of intended hours and the rate of successful cue delivery was 99 ± 2.7%. The system and program also were effective in motivating cued exercise: activity was detected within 5-s of the cue 98 ± 3.1% of the time. As shown via two case studies, accelerometry data can accurately reflect graded-challenge exercise instructions and reveal differentiable activity levels across exercise stages. User experience surveys indicated positive overall usability in the home settings, strong levels of personal motivation to use the system, and high degrees of satisfaction with the devices and provided training. Self-efficacy assessments indicated a strong perception of proficiency across participants (95 ± 5.0). CONCLUSIONS: This study demonstrates that a low-cost wearable system providing frequent haptic cues to encourage graded-challenge exercise after stroke can have utility and can provide an overall positive user experience in home settings. The study also demonstrates how combining a graded exercise program with all-day activity monitoring can provide insight into the potential for wearable systems to assess adherence to-and effectiveness of-home-based exercise programs on an individualized basis.

Extended training improves the accuracy and efficiency of goal-directed reaching guided by supplemental kinesthetic vibrotactile feedback.

Prior studies have shown that the accuracy and efficiency of reaching can be improved using novel sensory interfaces to apply task-specific vibrotactile feedback (VTF) during movement. However, those studies have typically evaluated performance after less than 1 h of training using VTF. Here, we tested the effects of extended training using a specific form of vibrotactile cues-supplemental kinesthetic VTF-on the accuracy and temporal efficiency of goal-directed reaching. Healthy young adults performed planar reaching with VTF encoding of the moving hand's instantaneous position, applied to the non-moving arm. We compared target capture errors and movement times before, during, and after approximately 10 h (20 sessions) of training on the VTF-guided reaching task. Initial performance of VTF-guided reaching showed that people were able to use supplemental VTF to improve reaching accuracy. Performance improvements were retained from one training session to the next. After 20 sessions of training, the accuracy and temporal efficiency of VTF-guided reaching were equivalent to or better than reaches performed with only proprioception. However, hand paths during VTF-guided reaching exhibited a persistent strategy where movements were decomposed into discrete sub-movements along the cardinal axes of the VTF display. We also used a dual-task condition to assess the extent to which performance gains in VTF-guided reaching resist dual-task interference. Dual-tasking capability improved over the 20 sessions, such that the primary VTF-guided reaching and a secondary choice reaction time task were performed with increasing concurrency. Thus, VTF-guided reaching is a learnable skill in young adults, who can achieve levels of accuracy and temporal efficiency equaling or exceeding those observed during movements guided only by proprioception. Future studies are warranted to explore learnability in older adults and patients with proprioceptive deficits, who might benefit from using wearable sensory augmentation technologies to enhance control of arm movements.

When intercepting moving targets, mid-movement error corrections reflect distinct responses to visual and haptic perturbations.

We examined a key aspect of sensorimotor skill: the capability to correct performance errors that arise mid-movement. Participants grasped the handle of a robot that imposed a nominal viscous resistance to hand movement. They watched a target move pseudo-randomly just above the horizontal plane of hand motion and initiated quick interception movements when cued. On some trials, the robot's viscosity or the target's speed changed without warning coincident with the GO cue. We fit a sum-of-Gaussians model to mechanical power measured at the handle to determine the number, magnitude, and relative timing of submovements occurring in each interception attempt. When a single submovement successfully intercepted the target, capture times averaged 410 ms. Sometimes, two or more submovements were required. Initial error corrections typically occurred before feedback could indicate the target had been captured or missed. Error corrections occurred sooner after movement onset in response to mechanical viscosity increases (at 154 ms) than to unprovoked errors on control trials (215 ms). Corrections occurred later (272 ms) in response to viscosity decreases. The latency of corrections for target speed changes did not differ from those in control trials. Remarkably, these early error corrections accommodated the altered testing conditions; speed/viscosity increases elicited more vigorous corrections than in control trials with unprovoked errors; speed/viscosity decreases elicited less vigorous corrections. These results suggest that the brain monitors and predicts the outcome of evolving movements, rapidly infers causes of mid-movement errors, and plans and executes corrections-all within 300 ms of movement onset.

Utility and Usability of Two Forms of Supplemental Vibrotactile Kinesthetic Feedback for Enhancing Movement Accuracy and Efficiency in Goal-Directed Reaching.

Recent advances in wearable sensors and computing have made possible the development of novel sensory augmentation technologies that promise to enhance human motor performance and quality of life in a wide range of applications. We compared the objective utility and subjective user experience for two biologically inspired ways to encode movement-related information into supplemental feedback for the real-time control of goal-directed reaching in healthy, neurologically intact adults. One encoding scheme mimicked visual feedback encoding by converting real-time hand position in a Cartesian frame of reference into supplemental kinesthetic feedback provided by a vibrotactile display attached to the non-moving arm and hand. The other approach mimicked proprioceptive encoding by providing real-time arm joint angle information via the vibrotactile display. We found that both encoding schemes had objective utility in that after a brief training period, both forms of supplemental feedback promoted improved reach accuracy in the absence of concurrent visual feedback over performance levels achieved using proprioception alone. Cartesian encoding promoted greater reductions in target capture errors in the absence of visual feedback (Cartesian: 59% improvement; Joint Angle: 21% improvement). Accuracy gains promoted by both encoding schemes came at a cost in terms of temporal efficiency; target capture times were considerably longer (1.5 s longer) when reaching with supplemental kinesthetic feedback than without. Furthermore, neither encoding scheme yielded movements that were particularly smooth, although movements made with joint angle encoding were smoother than movements with Cartesian encoding. Participant responses on user experience surveys indicate that both encoding schemes were motivating and that both yielded passable user satisfaction scores. However, only Cartesian endpoint encoding was found to have passable usability; participants felt more competent using Cartesian encoding than joint angle encoding. These results are expected to inform future efforts to develop wearable technology to enhance the accuracy and efficiency of goal-directed actions using continuous supplemental kinesthetic feedback.

Supplemental vibrotactile feedback of real-time limb position enhances precision of goal-directed reaching.

We examined vibrotactile stimulation as a form of supplemental limb state feedback to enhance planning and ongoing control of goal-directed movements. Subjects wore a two-dimensional vibrotactile display on their nondominant arm while performing horizontal planar reaching with the dominant arm. The vibrotactile display provided feedback of hand position such that small hand displacements were more easily discriminable using vibrotactile feedback than with intrinsic proprioceptive feedback. When subjects relied solely on proprioception to capture visuospatial targets, performance was degraded by proprioceptive drift and an expansion of task space. By contrast, reach accuracy was enhanced immediately when subjects were provided vibrotactile feedback and further improved over 2 days of training. Improvements reflected resolution of proprioceptive drift, which occurred only when vibrotactile feedback was active, demonstrating that benefits of vibrotactile feedback are due, in part to its integration into the ongoing control of movement. A partial resolution of task space expansion persisted even when vibrotactile feedback was inactive, demonstrating that training with vibrotactile feedback also induced changes in movement planning. However, the benefits of vibrotactile feedback come at a cognitive cost. All subjects adopted a stereotyped strategy wherein they attempted to capture targets by moving first along one axis of the vibrotactile display and then the other. For most subjects, this inefficient approach did not resolve over two bouts of training performed on separate days, suggesting that additional training is needed to integrate vibrotactile feedback into the planning and online control of goal-directed reaching in a way that promotes smooth and efficient movement. NEW & NOTEWORTHY A two-dimensional vibrotactile display provided state (not error) feedback to enhance control of a moving limb. Subjects learned to use state feedback to perform blind reaches with accuracy and precision exceeding that attained using intrinsic proprioception alone. Feedback utilization incurred substantial cognitive cost: subjects moved first along one axis of the vibrotactile display, then the other. This stereotyped control strategy must be overcome if vibrotactile limb state feedback is to promote naturalistic limb movements.

Spatial and temporal influences on discrimination of vibrotactile stimuli on the arm.

Body-machine interfaces (BMIs) provide a non-invasive way to control devices. Vibrotactile stimulation has been used by BMIs to provide performance feedback to the user, thereby reducing visual demands. To advance the goal of developing a compact, multivariate vibrotactile display for BMIs, we performed two psychophysical experiments to determine the acuity of vibrotactile perception across the arm. The first experiment assessed vibration intensity discrimination of sequentially presented stimuli within four dermatomes of the arm (C5, C7, C8, and T1) and on the ulnar head. The second experiment compared vibration intensity discrimination when pairs of vibrotactile stimuli were presented simultaneously vs. sequentially within and across dermatomes. The first experiment found a small but statistically significant difference between dermatomes C7 and T1, but discrimination thresholds at the other three locations did not differ. Thus, while all tested dermatomes of the arm and hand could serve as viable sites of vibrotactile stimulation for a practical BMI, ideal implementations should account for small differences in perceptual acuity across dermatomes. The second experiment found that sequential delivery of vibrotactile stimuli resulted in better intensity discrimination than simultaneous delivery, independent of whether the pairs were located within the same dermatome or across dermatomes. Taken together, our results suggest that the arm may be a viable site to transfer multivariate information via vibrotactile feedback for body-machine interfaces. However, user training may be needed to overcome the perceptual disadvantage of simultaneous vs. sequentially presented stimuli.

Following and intercepting scribbles: interactions between eye and hand control.

The smooth pursuit eye movement system appears to be importantly engaged during the planning and execution of interceptive hand movements. The present study sought to probe the interaction between eye and hand control systems by examining their responses during an interception task that included target speed perturbations. On 2/3 of trials, the target increased or decreased speed at various times, ranging from about 300 ms before to 150 ms after the onset of a finger movement directed to intercept the target and was triggered by a GO signal. Additionally, the same 2D sum-of-sines target trajectories were followed with the eyes without interception. The smooth pursuit system responded more quickly if the target speed perturbation occurred earlier during the reaction time (i.e., near the time of the GO signal). Similarly, the finger movement began more quickly if target speed was increased earlier during the reaction time. For early perturbation conditions, the initial direction of the finger movement matched the predicted target intercept using the new target speed. For perturbations occurring after finger movement, onset initial direction of finger movement did not match target interception such that the finger path began to curve toward the perturbed target after about 150-200 ms. The results support the idea of an active process of visual target path extrapolation simultaneously used to guide both the eye and hand.

Vibrotactile Perception for Sensorimotor Augmentation: Perceptual Discrimination of Vibrotactile Stimuli Induced by Low-Cost Eccentric Rotating Mass Motors at Different Body Locations in Young, Middle-Aged, and Older Adults.

Sensory augmentation technologies are being developed to convey useful supplemental sensory cues to people in comfortable, unobtrusive ways for the purpose of improving the ongoing control of volitional movement. Low-cost vibration motors are strong contenders for providing supplemental cues intended to enhance or augment closed-loop feedback control of limb movements in patients with proprioceptive deficits, but who still retain the ability to generate movement. However, it remains unclear what form such cues should take and where on the body they may be applied to enhance the perception-cognition-action cycle implicit in closed-loop feedback control. As a step toward addressing this knowledge gap, we used low-cost, wearable technology to examine the perceptual acuity of vibrotactile stimulus intensity discrimination at several candidate sites on the body in a sample of participants spanning a wide age range. We also sought to determine the extent to which the acuity of vibrotactile discrimination can improve over several days of discrimination training. Healthy adults performed a series of 2-alternative forced choice experiments that quantified capability to perceive small differences in the intensity of stimuli provided by low-cost eccentric rotating mass vibration motors fixed at various body locations. In one set of experiments, we found that the acuity of intensity discrimination was poorer in older participants than in middle-aged and younger participants, and that stimuli applied to the torso were systematically harder to discriminate than stimuli applied to the forearm, knee, or shoulders, which all had similar acuities. In another set of experiments, we found that older adults could improve intensity discrimination over the course of 3 days of practice on that task such that their final performance did not differ significantly from that of younger adults. These findings may be useful for future development of wearable technologies intended to improve the control of movements through the application of supplemental vibrotactile cues.

Vibration Propagation on the Skin of the Arm.

Vibrotactile interfaces are an inexpensive and non-invasive way to provide performance feedback to body-machine interface users. Interfaces for the upper extremity have utilized a multi-channel approach using an array of vibration motors placed on the upper extremity. However, for successful perception of multi-channel vibrotactile feedback on the arm, we need to account for vibration propagation across the skin. If two stimuli are delivered within a small distance, mechanical propagation of vibration can lead to inaccurate perception of the distinct vibrotactile stimuli. This study sought to characterize vibration propagation across the hairy skin of the forearm. We characterized vibration propagation by measuring accelerations at various distances from a source vibration of variable intensities (100-240 Hz). Our results showed that acceleration from the source vibration was present at a distance of 4 cm at intensities >150 Hz. At distances greater than 8 cm from the source, accelerations were reduced to values substantially below vibrotactile discrimination thresholds for all vibration intensities. We conclude that in future applications of vibrotactile interfaces, stimulation sites should be separated by a distance of at least 8 cm to avoid potential interference in vibration perception caused by propagating vibrations.

Target interception: hand-eye coordination and strategies.

This study was designed to define the characteristics of eye-hand coordination in a task requiring the interception of a moving target. It also assessed the extent to which the motion of the target was predicted and the strategies subjects used to determine when to initiate target interception. Target trajectories were constructed from sums of sines in the horizontal and vertical dimensions. Subjects intercepted these trajectories by moving their index finger along the surface of a display monitor. They were free to initiate the interception at any time, and on successful interception, the target disappeared. Although they were not explicitly instructed to do so, subjects tracked target motion with normal, high-gain smooth-pursuit eye movements right up until the target was intercepted. However, the probability of catch-up saccades was substantially depressed shortly after the onset of manual interception. The initial direction of the finger movement anticipated the motion of the target by approximately 150 ms. For any given trajectory, subjects tended to initiate interception at predictable times that depended on the characteristics of the target trajectories [i.e., when the curvature (or angular velocity) of the target was small and when the target was moving toward the finger]. The relative weighting of various parameters that influenced the decision to initiate interception varied from subject to subject and was not accounted for by a model based on the short-range predictability of target motion.