[ARTICLE] Enabling Stroke Rehabilitation in Home and Community Settings: A Wearable Sensor-Based Approach for Upper-Limb Motor Training – Full Text

A conceptual representation of the wrist-worn sensor system for home-based upper-limb rehabilitation. The system consists of two wearable sensors, a tablet computer to be… View more

Abstract:

High-dosage motor practice can significantly contribute to achieving functional recovery after a stroke. Performing rehabilitation exercises at home and using, or attempting to use, the stroke-affected upper limb during Activities of Daily Living (ADL) are effective ways to achieve high-dosage motor practice in stroke survivors. This paper presents a novel technological approach that enables 1) detecting goal-directed upper limb movements during the performance of ADL, so that timely feedback can be provided to encourage the use of the affected limb, and 2) assessing the quality of motor performance during in-home rehabilitation exercises so that appropriate feedback can be generated to promote high-quality exercise. The results herein presented show that it is possible to detect 1) goal-directed movements during the performance of ADL with a c -statistic of 87.0% and 2) poorly performed movements in selected rehabilitation exercises with an F -score of 84.3%, thus enabling the generation of appropriate feedback. In a survey to gather preliminary data concerning the clinical adequacy of the proposed approach, 91.7% of occupational therapists demonstrated willingness to use it in their practice, and 88.2% of stroke survivors indicated that they would use it if recommended by their therapist.

Introduction

Stroke is a leading cause of severe long-term disability. In the US alone, nearly 800,000 people suffer a stroke each year [1]. The number of individuals who suffer a stroke each year is expected to rise in the coming years because the prevalence of stroke increases with age and the world population is aging [2]. Approximately 85% of individuals who have a stroke survive, but they often experience significant motor impairments. Upper-limb paresis is the most common impairment following a stroke. It affects 75% of stroke survivors and leads to limitations in the performance of Activities of Daily Living (ADL) [4].

Inability to use the stroke-affected upper limb for ADL often leads to a phenomenon that is referred to as learned non-use [5]. As patients rely more and more on the unaffected (or less impaired) upper limb [5] they progressively lose motor abilities of the stroke-affected upper limb that they may have recovered as a result of a rehabilitation intervention [6].

A high dosage of motor practice using the stroke-affected upper limb during the performance of ADL, despite considerable difficulty, stimulates neuroplasticity and motor function recovery [7]–[8][9]. Thus, it is clinically important to encourage stroke survivors to continue making appropriate use of the affected upper limb [10]–[11][12][13], in addition to engaging in rehabilitation exercises that focus on range-of-motion and functional abilities [14]–[15][16].

The use of wearable sensors has recently emerged as an efficient way to monitor the amount of upper-limb use after a stroke [17]–[18][19][20][21][22]. However, despite growing evidence of the clinical potential of these devices [23], their widespread clinical deployment has been hindered by technical limitations. A shortcoming of currently available wrist-worn devices is that they cannot distinguish between Goal-Directed (GD) movements (i.e., movements performed for a specific purposeful task) and non-Goal-Directed (non-GD) movements (e.g., the arm swinging during gait). Instead, these sensors focus on recording the number and/or intensity of any type of arm movements [10]. Consequently, non-GD movements are reflected as part of the measurements with equal importance as GD movements. This results in an overestimation of the amount of actual arm use [24]. Furthermore, monitoring the aggregate number of stroke-affected upper limb movements is not sufficient for the purpose of providing timely feedback to encourage the use of the affected limb during the performance of ADL. To promote the use of the stroke-affected limb, it is critical that feedback reflects the relative use of the affected upper limb compared to the contralateral one.

Wrist-worn movement sensors have also been applied to monitoring rehabilitation exercises in the home setting [25]–[26][27][28]. However, existing systems primarily focus on quantifying the dosage/intensity of the exercises (e.g., the duration of the exercises and the number of movement repetitions) and do not monitor if the quality of the performed exercise is appropriate. Ensuring good quality of movement during the performance of rehabilitation exercises is critical for maximizing functional recovery after a stroke [29]. Moreover, providing customized feedback regarding the quality of exercise movements can increase motivation, promote long-term adherence to a prescribed exercise regimen, and ultimately maximize clinical outcomes [30]. One of the reasons for limited exercise participation by stroke survivors is the lack of access to resources to support exercise including performance feedback from rehabilitation specialists [31]. There are no technical solutions that provide feedback regarding the quality of exercise performance for upper-limb rehabilitation after stroke.

We propose a system for aiding in functional recovery after a stroke that consists of two wearable sensors, one worn on the stroke-affected upper limb and the other on the contralateral upper limb [32] (Fig. 1). The proposed system can be used to provide timely feedback when ADL are performed. If the system detects that the patient consistently performs GD movements with the unaffected upper limb, and rarely uses the stroke-affected upper limb, then a visual or vibrotactile reminder can be triggered to encourage the patient to attempt GD movements with the stroke-affected limb. A benefit of this approach is that if a movement is critical (e.g., signing a check), patients can use the unaffected upper limb without receiving negative feedback as long as they have performed a sufficient number of movements with the affected upper limb throughout the day. Furthermore, the system promotes high-dosage motor practice with appropriate feedback to extend components of rehabilitation interventions into the home environment.[…]

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