Posts Tagged home-based

[Abstract] Requirements for a home-based rehabilitation device for hand and wrist therapy after stroke

Abstract

Recovering hand function to perform activities of
daily living (ADL), is a significant step for stroke survivors
experiencing paresis in their upper limb. A home-based, robot
mediated training approach for the hand allows the patient to
continue their training independently after discharge to maximise
recovery at the patient’s pace. Developing such a hand/wrist
training device that is comfortable to wear and easy to use is the
objective of this work. Using a user-centred design approach, the
first iteration of the design is based on the requirements derived
from the users and therapists, leading to a first prototype. The
prototype is then compared and evaluated against the required
features. This paper highlights the methodology used in the
process of validating the design against our initial brief.

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[REVIEW] A scoping review of design requirements for a home-based upper limb rehabilitation robot for stroke – Full Text

ABSTRACT

Background

Home-based robotic therapy is a trend of post-stroke upper limb rehabilitation. Although home-based upper limb rehabilitation robots have been developed over several decades, no design specification has been published.

Objectives

To identify and synthesize design requirements considering user and technology needs for a home-based upper limb rehabilitation robot through a scoping review.

Method

Studies published between 1 January 2000 and 10 June 2020 in Scopus, Web of Science and PubMed database regarding design requirements for upper limb rehabilitation robots from of stroke survivors or therapists were identified and analyzed. We use ‘requirement’ as something that is needed or wanted. Two physiotherapists ranked the requirements identified from literature review.

Results

Nine studies were selected for review. They identified 42 requirements regarding functionality (n = 11, 26.2% of total requirements), usability (n = 16, 38.0% of total requirements), software (n = 14, 33.3% of total requirements) and safety (n = 1, 2.4% of total requirements). The main implementation barriers with respect to adherence and monitoring were space, operation, and cost.

Conclusion

This is the first research to summarize the design requirements for home-based upper limb rehabilitation robots for stroke survivors. The need for a safe, comfortable, easy to use device which can be individualized and promote specific movements and tasks emerged. The result of this paper captures the design requirements that can be used in future for the development of a design specification. It provides designers and researchers guidance about the real-world needs for home-based upper limb rehabilitation robots for stroke.

Background

Stroke is one of the most common and disabling health care problems in the world.1 Annually approximately 33 million people suffer a stroke worldwide2,3; more than 1 million people suffer from stroke in Europe and 100,000 in the United Kingdom (UK).4 Up to 85% of stroke survivors suffer upper limb weakness and recovery is often limited.5–7 Therefore, improving functionality of the upper limb is a major aim of post-stroke rehabilitation. The most effective intervention to improve upper limb recovery is high repetition task-specific training,8–10 however this is difficult to achieve as healthcare systems are resource limited, especially for stroke survivors who are unable to move their limb without assistance. One way to increase the intensity of practice is to use robotic devices to provide this assistance.8,11

Since the first use of MIT-MANUS in the clinical environment in 1994, robotic-assisted therapy has entered a new era12,13 and several upper limb rehabilitation robots have been developed including the Mirror Image Motion Enable (MIME) and Automatic Recovery Arm Motility Integrated System (ARAMIS).14–18 However, the evidence of the effectiveness of robotic-assisted therapy is mixed17,18 and they have not as yet been widely adopted into clinical practice. One reason for this may be the logistics of their use. Patients for whom a rehabilitation robot is indicated are severely disabled and so regular clinic visits for treatment are difficult; expensive; time consuming and fatiguing and patients only receive relatively low doses of therapy. Post-hospital rehabilitation is primarily delivered in patients’ home at present.19 Thus, to be integrated into clinical practice, upper limb rehabilitation robots need to be suitable for deployment in patients’ homes which will allow unlimited access to assisted therapy enabling higher frequency and higher intensity.

Several researchers have designed and shown the potential benefit of home-based rehabilitation robots, such as MARIONET, Bi-Manu-Track and hCAAR.20–22 Although some studies collected or analyzed stroke survivors’ or therapists’ requirements for rehabilitation robots,23–25 there is no systematic analysis of design requirement for home-based upper limb rehabilitation robots.

The aim of this scoping review is to identify the clinical and technology design requirements and the implementation barriers for home-based rehabilitation robots. The results of this research will help designers and researchers understand the real-world needs for home-based upper limb rehabilitation robots enabling them to develop new systems which are fit for purpose.

Method

Search strategy

Scopus, Web of Science and PubMed were searched using the following search categories: “stroke,” “upper limb,” “home-based,” “rehabilitation robot,” “user,” and “requirement.” The search terms used were (design or speci* or require* or consideration or need) AND (robot* or rehab* system or rehab* technology) AND (upper limb or upper extremity) AND (user or clinic* or patient or stroke survivor) AND (home based or setting or environment) AND (stroke).

The titles, abstract, and then full texts were screened for papers which met the following selection criteria:

  1. Related to a robot device or robotic-assisted system for stroke survivors with upper limb impairments.
  2. Including mechanical or medical device design requirements, specification or consideration for a home-based upper limb rehabilitation robot.
  3. Including patients’, therapists’ or users’ requirements on home-based rehabilitation robot.
  4. Published from 1 January 2000 to 10 June 2020, because there was no research on design requirements of home-based rehabilitation robots before 1 January 2000.

Exclusion criteria were:

  1. Not written in English.
  2. Describing an exoskeleton device.
  3. Describing wheelchair-based devices, as this type device assists movement of disabled arm rather rehabilitation.

This research followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses – Extension for Scoping Reviews (PRISMA-ScR) (Appendix 1).

Ranking strategy

To identify the importance level for each requirement, two experienced physiotherapists ranked identified requirements through online questionnaire. We divided the importance level from high to low into four levels: 1) essential/non-negotiable; 2) important – usability or effectiveness would be comprised if not present; 3) desirable – nice to have but the robot would be functional without and it would increase attractiveness or breadth of application; 4) unnecessary – could live without it. In order to analyze the ranking results, we assumed the importance value of each importance level, from 4 to 1 representing from high to low. Final importance value was represented by the average of the two responses.

Results

From 737 studies identified through the initial database search, nine were included in the final scoping review. Studies were omitted, and additional papers included, through the processes given in Figure 1.

Figure 1. Flowchart of study selection

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[Abstract + References] A Home-Based Upper Limb-Rehabilitation Service System for Patients with Mild-Stroke – Conference paper

Abstract

With the increase in the number of stroke patients in China and the rehabilitation service requirements, the conventional hospital rehabilitation model can no longer cater to the individual needs of patients. Upper limb motor dysfunction is the most prevalent symptom leading to reduced capacity of patients. Therefore, rehabilitation training is vital to the recovery of limb motor function in stroke hemiplegia patients. The authors conduct research on the upper limb recovery in mild stroke patients in China. During the research, the authors adopt methods including literature review, case study, field research, interviews, and so on, to observe and study the medical treatment and life patterns of mild-stroke patients, also to explore their needs through multiple iterations. The research utilizes the human-centered design principle and ergonomics paradigms and finally produces a home-based rehab service system design.

References

  1. 1.Mozaffarian, D., et al.: Heart disease and stroke statistics-2016 update a report from the American Heart Association. Circulation 133(4), e38–e48 (2016)Google Scholar
  2. 2.Fregni, F., Pascual-Leone, A.: Hand motor recovery after stroke: tuning the orchestra to improve hand motor function. Cogn. Behav. Neurol. 19(1), 21–33 (2006)CrossRefGoogle Scholar
  3. 3.Lawrence, E.S., et al.: Estimates of the prevalence of acute stroke impairments and disability in a multiethnic population. Stroke 32(6), 1279–1284 (2001)CrossRefGoogle Scholar
  4. 4.Nichols-Larsen, D.S., Clark, P.C., Zeringue, A., Greenspan, A., Blanton, S.: Factors influencing stroke survivors’ quality of life during subacute recovery. Stroke 36(7), 1480–1484 (2005)CrossRefGoogle Scholar
  5. 5.Liu, L., Wang, D., Wong, K.L., Wang, Y.: Stroke and stroke care in China: huge burden, significant workload, and a national priority. Stroke 42(12), 3651–3654 (2011)CrossRefGoogle Scholar
  6. 6.Wu, Z.Y., Chong, H., Zhao, D.: Epidemiological study on the incidence and mortality of stroke in Chinese population. Chin. J. Epidemiol. 24(3), 236–239 (2003)Google Scholar
  7. 7.TeachMe Series: The upper Limb (2020). https://teachmeanatomy.info/upper-limb/
  8. 8.Drake, R., Vogl, A.W., Mitchell, A.W.: Gray’s Anatomy for Students E-Book. Elsevier Health Sciences, Philadelphia (2009)Google Scholar
  9. 9.Reiss, A.P., Wolf, S.L., Hammel, E.A., McLeod, E.L., Williams, E.A.: Constraint-induced movement therapy (CIMT): current perspectives and future directions. Stroke Res. Treat. 2012 (2012). Article ID: 159391Google Scholar
  10. 10.Stoykov, M.E., Corcos, D.M.: A review of bilateral training for upper extremity hemiparesis. Occup. Ther. Int. 16(3–4), 190–203 (2009)CrossRefGoogle Scholar
  11. 11.Yoo, C., Park, J.: Impact of task-oriented training on hand function and activities of daily living after stroke. J. Phys. Ther. Sci. 27(8), 2529–2531 (2015)CrossRefGoogle Scholar
  12. 12.Kim, W.S., Cho, S., Baek, D., Bang, H., Paik, N.J.: Upper extremity functional evaluation by Fugl-Meyer assessment scoring using depth-sensing camera in hemiplegic stroke patients. PLoS ONE 11(7), e0158640 (2016)CrossRefGoogle Scholar
  13. 13.Fan, X.S.: Design study of household hand rehabilitation products for stroke patients. Master thesis. DongHua University, China (2017)Google Scholar
  14. 14.Fugl-Meyer, A.R., Jääskö, L., Leyman, I., Olsson, S., Steglind, S.: The post-stroke hemiplegic patient. 1. A method for evaluation of physical performance. Scand. J. Rehabil. Med. 7(1), 13–31 (1975)Google Scholar

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[Abstract] Effects of home-based dual-hemispheric transcranial direct current stimulation combined with exercise on upper and lower limb motor performance in patients with chronic stroke

Abstract

Purpose

This study aimed to determine the effects of home-based dual-hemispheric transcranial direct current stimulation (dual-tDCS) combined with exercise on motor performance in patients with chronic stroke.

Materials and methods

We allocated 24 participants to the active or sham group. They completed 1-h home-based exercise after 20-min dual-tDCS at 2-mA, thrice a week for 4 weeks. The patients were assessed using the Fugl–Meyer Assessment (FMA), Wolf Motor Function Test, Timed Up and Go test, Five Times Sit-to-Stand Test, Six-meter Walk Test, and muscle strength assessment.

Results

Compared with the sham group, the active group showed improved FMA scores, which were sustained for at least 1 month. There was no between-group difference in the outcomes of the functional tasks.

Conclusion

Home-based dual-tDCS could facilitate motor recovery in patients with chronic stroke with its effect lasting for at least 1 month. However, its effects on functional tasks remain unclear. tDCS is safe and easy for home-based self-administration for patients who can use their paretic arms. This could benefit patients without access to health care centres or in situations requiring physical distancing. This home-based tDCS combined with exercise has the potential to be incorporated into telemedicine in stroke rehabilitation.

  • IMPLICATIONS FOR REHABILITATION
  • Twelve sessions of home-based dual-tDCS combined with exercises (3 days/week for 4 weeks) facilitated upper and lower limb motor recovery in patients with chronic stroke compared with exercise alone, with a post-effect for at least 1 month.
  • Home-based tDCS could be safe and easily self-administrable by patients who can use their paretic arms.
  • This intervention could be beneficial for patients living in the community without easy access to a health care centre or in situations where physical distancing is required.

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[ARTICLE] Effect of combined home-based, overground robotic-assisted gait training and usual physiotherapy on clinical functional outcomes in people with chronic stroke: A randomized controlled trial – Full Text

Abstract

Objectives:

To assess the effect of a home-based over-ground robotic-assisted gait training program using the AlterG Bionic Leg orthosis on clinical functional outcomes in people with chronic stroke.

Design:

Randomized controlled trial.

Setting:

Home.

Participants:

Thirty-four ambulatory chronic stroke patients who recieve usual physiotherapy.

Intervention:

Usual physiotherapy plus either (1)10-week over-ground robotic-assisted gait training program (n = 16), using the device for ⩾30 minutes per day, or (2) control group (n = 18), 30 minutes of physical activity per day.

Measurements:

The primary outcome was the Six-Minute Walk Test. Secondary outcomes included: Timed-Up-and-Go, Functional Ambulation Categories, Dynamic Gait Index and Berg Balance Scale. Physical activity and sedentary time were assessed using accelerometry. All measurements were completed at baseline, 10 and 22 weeks after baseline.

Results:

Significant increases in walking distance were observed for the Six-Minute Walk Test between baseline and 10 weeks for over-ground robotic-assisted gait training (135 ± 81 m vs 158 ± 93 m, respectively; P ⩽ 0.001) but not for control (122 ± 92 m vs 119 ± 84 m, respectively). Findings were similar for Functional Ambulation Categories, Dynamic Gait Index and Berg Balance Scale (all P ⩽ 0.01). For over-ground robotic-assisted gait training, there were increases in time spent stepping, number of steps taken, number of sit-to-stand transitions, and reductions in time spent sitting/supine between baseline and 10 weeks (all P < 0.05). The differences observed in all of the aforementioned outcome measures were maintained at 22 weeks, 12 weeks after completing the intervention (all P > 0.05).

Conclusion:

Over-ground robotic-assisted gait training combined with physiotherapy in chronic stroke patients led to significant improvements in clinical functional outcomes and physical activity compared to the control group. Improvements were maintained at 22 weeks.

Introduction

Robotic devices provide high-intensity, repetitive, task-specific therapy and have been shown to improve gait quality (i.e., stride length, step length), functional outcomes (i.e. walking speed and walking capacity) and motor performance in stroke patients.1 Stroke patients with greater functional ability may benefit more from over-ground robotic-assisted gait training opposed to treadmill-based robotics (e.g., Lokomat and LOPES) and end effector devices, which moves the patients in a gait like pattern driven by two movable footplates (e.g., G-EO).

Over-ground robotic-assisted devices allow the patient to walk in a real-world environment,2 encourages trunk and balance control,3 and allows for substantial kinematic variability while still ensuring successful task execution. A small number of training case series46 and a single randomized controlled trial7 have found modest functional benefits7 and improvements in gait speed, endurance, and balance after completing an over-ground robotic-assisted gait training intervention, lasting ⩽ six weeks.46 However, interventions which last greater than eight weeks may accelerate walking gains and improve functional capacity.8 It is plausible that longer programs may elicit greater functional improvements in stroke patients.

The primary use of robotic devices is within a clinical setting, as many available systems are not yet developed for a home-based environment and/or require a trained therapist to operate them. Robotic devices are expensive and research is needed to establish the benefit to cost ratio, and potential risk of harm associated with a device if used within a home-based environment. The “at home” potential, however, of an over-ground robotic-assisted gait training device could potentially improve the efficiency of therapy treatments enabling physiotherapists to implement rehabilitation without being physically present.9 Home-based settings may also be efficacious as patients could use such devices more frequently in a familiar context10 contributing to the formation of habits leading to long-term behavior change.11 Further research is needed to investigate the feasibility, efficacy and application of over-ground robotic-assisted gait training in a home-based environment.

The purpose of this study was to assess the effect of a 10-week home-based rehabilitation program using a lower limb dynamic over-ground robotic-assisted gait training device, in combination with usual care physiotherapy, in ambulatory stroke patients on clinical functional outcomes. It was hypothesized that regular participation in a 10-week over-ground robotic-assisted gait training program would improve functional outcomes in individuals living with stroke. A secondary hypothesis was that over-ground robotic-assisted gait training would increase physical activity and reduce sedentary behavior.


Methods

This study was a dual-center, parallel group, randomized controlled clinical trial, reported in accordance with CONSORT (Consolidated Standards of Reporting Trials) guidelines.12 The study protocol received institutional ethical approval from the University of Winchester (Approval number BLS/16/16) and was registered with the Clinical Trials.gov Protocol Registration and Results System (NCT03104127). The study was funded by the University of Winchester. AlterG Bionic Leg orthoses were provided freely by AlterG (Bionic Leg orthosis, Fremont, CA, USA) who had no input or influence on the data analysis or manuscript preparation. Recruitment started in April 2017 and ended in July 2019.

Participants with chronic stroke (> three months since stroke diagnosis) were identified, screened for eligibility, which included a health history questionnaire, and recruited from a single neuro-physiotherapy practice (Hobbs Rehabilitation, Winchester, UK). All participants were diagnosed with stroke by a specialist neurologist/stroke consultant from a UK National Health Service (NHS) Trust and had undertaken normal inpatient and outpatient rehabilitation in accordance with recommended guidelines.13 Eligible participants were contacted by telephone and invited to attend a baseline assessment at the University. Written informed consent was obtained from all participants prior to the commencement of the study.

Study inclusion criteria were: individuals who were between 3 months and 5 years post-stroke at the time of study enrolment, who were community-dwelling, medically stable, and cognitively capable, able to stand and step with an aid or with assistance (defined as a Functional Ambulation Categories between 2 and 5),14 and who were either currently receiving physiotherapy or attending a community-based, stroke support group. Exclusion criteria were: Unresolved deep vein thrombosis, unstable cardiovascular conditions, open wounds, active drug resistant infection, recent fractures of involved limb, peripheral arterial disease, incontinence, severe osteoporosis, and/or non-weight bearing.

Participants completed a baseline assessment and follow-up assessments at 10 and 22 weeks after baseline. On completion of the baseline assessment, participants were randomized to either:

  • (i) a 10-week home-based over-ground robotic-assisted gait training program, including weekly “usual care” physiotherapy (O-RAGT).
  • (ii) a 10-week “usual care” physiotherapy only program (CON).

Web-based randomization was prepared by an independent researcher with no clinical involvement in the trial, using covariate adaptive randomization.15 In this study, participants were sequentially assigned to over-ground robotic-assisted gait training or control by taking into account the following covariates:

  • (i) Baseline postural sway (only able to stand with an aid versus able to stand unaided; able to stand ⩽two minutes versus able to stand > two minutes).
  • (ii) Age (age ⩾ 70 years vs <70 years).

The independent researcher informed the participant of group allocation at the end of the baseline assessment. Although participants and the primary researcher collecting outcome data were aware of the allocated treatment condition, in order to control and minimize investigator bias, data analysts were kept blinded to the allocation using an independent researcher to re-code the original data sets before returning the data to the data analyst. Identical assessments to those implemented at baseline, were administered at 10 and 22 weeks after baseline.

Participants were asked to abstain from any moderate-to-strenuous physical activity 24 hours prior to the baseline assessment. During this assessment, a series of clinical functional outcomes were measured, wherein participants could use walking aids (e.g., canes, orthoses) if necessary. The primary outcome for this study was the Six Minute Walk Test as it provides an overall measure of an individual’s walking ability, indicates physical incapacity, and is sensitive to change as a result of rehabilitation therapy which targets walking performance.16 The Six Minute Walk Test was conducted indoors on a flat walkway. Participants were required to walk between two cones 10m apart for a total of six minutes and were instructed to complete as far a distance as possible. At the end of the Six Minute Walk Test, participants also reported their terminal Ratings of Perceived Exertion (RPE).17

The secondary outcomes included: the Timed-Up-and-Go,18 Dynamic Gait Index,19 Berg Balance Scale,20 Functional Ambulation Categories,14 Modified Rankin Scale21 and accelerometry (ActivPAL3™ device, PAL Technologies Ltd., Glasgow, Scotland). The ActivPAL3 is an electronic logger that uses static and dynamic accelerometry data to distinguish between sitting/lying, standing, and stepping. The ActivPAL3 device was wrapped in a protective Tegaderm™ (3M, St Paul, USA) and attached to the anterior aspect of the upper third of the thigh, on the asymptomatic side. Participants wore the ActivPAL3 for seven consecutive days and nights. This process was repeated at the 10- and 22-week assessment. The physical activity data were categorized by the ActivPAL3 as: (1) percentage of time spent sitting or lying, (2) percentage of time spent standing, (3) percentage of time spent stepping, and (4) step counts.

The over-ground robotic-assisted gait training device (Alter-G, Bionic Leg orthosis, Fremont, CA, USA) is an externally-wearable, battery-operated dynamic device that helps patients and therapists during rehabilitation by providing adjustable and progressive functional mobility training (Figure 1). The device consists of an orthosis shell and an actuation unit. The orthosis shell functions as the user interface that transfers the assistive torque to the human body, while the actuation unit assists the movement of the limb which has been shown to be stable, smooth and similar to biological knee motion during sit-to-stand exercises.6 The over-ground robotic-assisted gait training device acts to supplement existing muscle strength, provide sensory inputs (i.e. auditory and sensory feedback) and mobility assistance for users with impaired lower-extremity function during rehabilitation (see Supplemental Information), and is fitted and worn in a manner similar to an orthopedic knee brace.


                        figure
Figure 1. Front and side view of the over-ground robotic-assisted gait training device (Alter G Bionic Leg orthosis, Fremont, CA, USA).

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[ARTICLE] The WeReha Project for an Innovative Home-Based Exercise Training in Chronic Stroke Patients: A Clinical Study

ABSTRACT

Background: Telerehabilitation (TR) in chronic stroke patients has emerged as a promising modality to deliver rehabilitative treatmentat-home. The primary objective of our methodical clinical study was to determine the efficacy of a novel rehabilitative device in terms of recovery of function in daily activities and patient satisfaction and acceptance of the medical device provided.

Methods: A 12-week physiotherapy program (balance exercises, upper and lower limb exercises with specific motor tasks using a biofeedback system and exergaming) was administered using the WeReha device. Twenty-five (N =25) chronic stroke outpatients were enrolled, and the data of 22 patients was analyzed. Clinical data and functional parameters were collected by Berg Balance scale (BBS), Barthel Index (BI), Fugl-Meyer scale (FM) , Modified Rankin scale (mRS), and Technology Acceptance Model (TAM) questionnaire at baseline (T0), after treatment (T1), and at the 12-week follow-up (T2). Statistical tests were used to detect significant differences (P < .05), and Cohen’s (Co) value was calculated.

Results: BI scores improved significantly after treatment (P=.036; Co 0.776, medium), as well as BBS scores (P=.008; Co 1.260, high). The results in FM scale (P=.003) and mRS scores (P=.047) were significant post treatment. Follow-up scores remained stable across all scales, except the BI. The A and C sub-scales of the TAM correlated significantly to only a T2 to T1 difference for BI scores with P=.021 and P=.042.

Conclusion: Currently, the WeReha program is not the conventional therapy for stroke patients, but it could be an integrative telerehabilitative resource for such patients as a conventional exercise program-at-home.

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[ARTICLE] Characterization and wearability evaluation of a fully portable wrist exoskeleton for unsupervised training after stroke – Full Text

Abstract

Background

Chronic hand and wrist impairment are frequently present following stroke and severely limit independence in everyday life. The wrist orientates and stabilizes the hand before and during grasping, and is therefore of critical importance in activities of daily living (ADL). To improve rehabilitation outcomes, classical therapy could be supplemented by novel therapies that can be applied in unsupervised settings. This would enable more distributed practice and could potentially increase overall training dose. Robotic technology offers new possibilities to address this challenge, but it is critical that devices for independent training are easy and appealing to use. Here, we present the development, characterization and wearability evaluation of a fully portable exoskeleton for active wrist extension/flexion support in stroke rehabilitation.

Methods

First we defined the requirements, and based on these, constructed the exoskeleton. We then characterized the device with standardized haptic and human-robot interaction metrics. The exoskeleton is composed of two modules placed on the forearm/hand and the upper arm. These modules weigh 238 g and 224 g, respectively. The forearm module actively supports wrist extension and flexion with a torque up to 3.7 Nm and an angular velocity up to 530 deg/s over a range of 154. The upper arm module includes the control electronics and battery, which can power the device for about 125 min in normal use. Special emphasis was put on independent donning and doffing of the device, which was tested via a wearability evaluation in 15 healthy participants and 2 stroke survivors using both qualitative and quantitative methods.

Results

All participants were able to independently don and doff the device after only 4 practice trials. For healthy participants the donning and doffing process took 61 ±15 s and 24 ±6 s, respectively. The two stroke survivors donned and doffed the exoskeleton in 54 s/22 s and 113 s/32 s, respectively. Usability questionnaires revealed that despite minor difficulties, all participants were positive regarding the device.

Conclusions

This study describes an actuated wrist exoskeleton which weighs less than 500 g, and which is easy and fast to don and doff with one hand. Our design has put special emphasis on the donning aspect of robotic devices which constitutes the first barrier a user will face in unsupervised settings. The proposed device is a first and intermediate step towards wearable rehabilitation technologies that can be used independently by the patient and in unsupervised settings.

Background

Stroke affects approximately 795’000 people each year in the US alone and is one of the leading causes of long-term adult disability and dependency [1]. Traditional stroke rehabilitation options for outpatients include therapist-based treatments with hands-on physical and occupational therapy in rehabilitation centres. The treatment lasts several weeks and is composed of periodic blocked practice, but overall training time remains low compared to the time the patient is inactive at home [23]. Moreover, stroke patients are discharged at an increasingly early stage [45] requiring new approaches for rehabilitation training in unsupervised settings. These novel approaches must be effective [67], and empower patients to self-initiate rehabilitation training that will enable more distributed sessions. This is particularly important since, in the future, more rehabilitation resources will be moved to community settings and patient homes to complement conventional therapy [811].

Upper extremity hemiparesis is a common weakness following stroke and heavily impairs ADL [12]. Adequate wrist function is critical for orientating and stabilising the hand [13], but the recovery process of this specific joint is still not well understood in stroke survivors [14]. It has been shown that the probability of recovering distal functions (e.g. the wrist) are closely linked with the acute state of proximal functions (shoulder or elbow) [15]. In the same vein, distal training can lead to positive effects at the shoulder and elbow [1618]. While the hand has received a lot of attention from the research community, there remains a need to provide wrist function training.

Robot-assisted therapy for stroke patients is a promising approach [1920] and proven advantages include: 1) increasing dose and intensity of training [2123], 2) allowing quantitative measurements to assess performance and recovery of the patient more precisely than conventional rehabilitation training [24], and 3) engaging the patient in a motivating and stimulating environment [2526]. However, a robot-mediated therapy administered in unsupervised settings implies several technical, clinical and social challenges: first of all, the technology must be safe to be deployed in such a context, its footprint acceptable to the patient, relatives and caregivers, and it should adhere to conventional therapy principles to administer appropriate treatment to the user. Moreover, the device must be adaptable to the individual and designed such that patients can use it independently and in various environmental settings [2729].

A myriad of devices have targeted training of the whole arm, and also more specifically the hand and fingers [192030], while relatively few wearable exoskeletons have focused on the wrist [3135]. Unlike stationary rehabilitation devices [3638], a fully wearable exoskeleton offers the possibility to use (i.e. to train) the paretic limb during functional everyday tasks [73940] where higher training dose could more conveniently be achieved. Exoskeletons interact at the level of individual joints and enable joint specific kinematic assessments [4142]. Moreover, it has been shown that training isolated individual joint movements facilitates learning complex multi-joint movements [4344]. Practically, this means that through the “part-whole transfer paradigm” simple low degree of freedom (DoF) robotic devices could facilitate the training of more complex movements. In an unsupervised training context, simplicity is paramount [45], therefore, simple wearable technologies might provide an interesting add-on to a conventional therapy where complex movements are trained.

We have previously presented a first prototype version of the eWrist [46]. Here we present further developments which focussed on improving portability, independence of use and adaptability in view of unsupervised use of the system. The eWrist is a fully wearable single DoF sEMG-based force controlled wrist exoskeleton that actively supports extension and flexion. We put special emphasis on the attachment mechanisms that facilitate the donning and doffing of the device so that a hemiparetic patient could mount the device independently with a single hand. Among the vast amount of published work on rehabilitation devices for in-home therapy, few have addressed the fixation issue, which constitutes the first barrier a user would have to overcome in order to use the device independently [4748]. Currently the eWrist is intended to be used as a training device rather than as an assistive exoskeleton during ADL. However, our long term design goal is to fuse training and assistance with the aim of increasing movement of the affected arm in daily life via technology that modulates assistance in order to improve upper arm function. This requires an exoskeleton that is fully wearable, easy to use, and especially simple to don and doff. The eWrist is our first wearable prototype that is capable of assisting wrist flexion and extension, the latter being particularly relevant for post stroke recovery [49].

Here we briefly describe the previous eWrist version, we then outline requirements for a fully wearable wrist exoskeleton and present an advanced eWrist device where we focussed on wearability improvements. We first characterize the current implementation based on standardized haptic and human-robot interaction metrics for rehabilitation devices. Secondly, we present the results of a wearability study which evaluates the donning/doffing procedure in healthy and stroke participants. Finally, limitations of the current work and potential future use of the eWrist are discussed.

Methods

Previous version of the eWrist

We previously introduced the eWrist [46], an exoskeleton actuated by a DC motor via bevel gears that actively supports wrist extension/flexion movements, measures force exerted on the handle, absolute angular position and velocity at the wrist axis via a Hall sensor integrated on the motor shaft. This prototype had several shortcomings, the major one being the overall weight of the exoskeleton (505 g total weight, of which 340 g was located on the forearm and hand). The current version of the eWrist includes the following improvements: (i) lowering the weight of the forearm module and reducing its physical profile by implementing a lighter and smaller motor, and by moving as many components as possible to more proximal areas, (ii) increasing the durability of the eWrist by implementing metal gears and an absolute angular Hall encoder, (iii) integrating an improved electronic design to simplify debugging and interaction with the device, and (iv) facilitating the overall donning/doffing via a completely redesigned mechanism for the upper arm module.

Design requirements

Our aims were to reduce the distal weight of the eWrist and most importantly to develop user-friendly mechanisms that allow one-handed donning and doffing of the whole exoskeleton. In the following sections we establish the requirements.

Transmission type

Three general transmission types are commonly seen in wearable exoskeletons, namely: pneumatic, cable-driven and linear actuators (DC motors) [50]. Pneumatic systems are compliant and adapt their shape to the human body but accurate control is difficult to implement because of non-linearities. Moreover, several components such as pump, reservoir, regulator and valves are inherent to these systems which make the integration into fully wearable solutions tedious [335152]. Cable-driven systems offer high compliance and low physical profile at the distal extremity while requiring less supplementary components then pneumatics. However, backlash and transmission losses make such systems challenging to control [5355]. Linear actuators and direct DC motor actuation are straightforward to implement and allow high controllability of position, speed and torque. Nevertheless, special attention to weight and backdrivability must be paid when placed distally and directly mounted to the paretic limb [325658].

Actuation output torque, velocity and RoM

A minimal RoM of 140 (70 in flexion and extension) and an output torque at the wrist up to 3 Nm were chosen as design criteria based on previous work [135960]. An angular velocity up to 180 deg/s (3.14 rad/s) was considered appropriate in a rehabilitation context, and subsequently in a daily life assistive context.

Sensing

When backdrivability of a transmission mechanism is not ensured, i.e. force (torque) cannot be assessed in the reverse direction (i.e. from limb to motor) by measuring the motor’s current draw, a common solution is to implement a force/torque sensor (load cell) serially connected with the joint kinematics [61]. Moreover, the absolute angular position of the wrist joint is needed and can either be achieved through initialization of motor encoders or with an additional absolute angular sensor.

Anatomical positioning

Compliant exoskeletons adapt to the biological joint and therefore do not require precise positioning [3362]. Rigid exoskeletons on the other hand, although much easier to control, need their mechanical axes to be aligned to the anatomical joint in order to not hinder movements or cause discomfort [325763].

Fixation

Attachment systems play a major role in the ergonomics and usability of wearable devices [4748]. Velcro and straps are a common, quickly implemented and therefore favoured solution to attach exoskeletons to the human body [5664]. However, these fixation techniques can be highly challenging if the user has to perform them with a single hand. For that reason, novel techniques need to be implemented to ensure that the whole exoskeleton attachment can be performed with a single hand and in reasonable time (<2 min) [6566]. Furthermore, the fixation systems must fulfil certain requirements in term of attachment strength and stability, and should also remain compliant to changes in body shape during movements [67].

Weight, size and ergonomics

Stroke survivors are highly sensitive to mechanical loads applied on their paretic limb, and even more so when the load is located distally [6869]. Moreover, an acceptable weight for a wrist exoskeleton is subjective and essentially patient specific [7071]. According to a previous study [53], an ideal upper benchmark weight for a wrist exoskeleton placed distally is 250g. This is often achieved by moving parts that are not directly required for actuation (e.g. battery, controller and others) to more proximal body parts [395372].

In order to limit the creation of shear forces and pressure on the skin, a short fixation structure is preferred for the forearm part of the exoskeleton. In this way, the pronation and supination of the forearm is less hindered and ergonomics enhanced [6373]. Regarding fixation to the hand, a palm free of attachments is desired to promote hand interaction with the environment [3353].

Finally, for the sake of ergonomics, the donning process and ultimately set-up time, the wearable device should be entirely located on the arm or in a position that does not hinder any movements of other joints (e.g. elbow/shoulder) or actions (e.g. sitting on a chair or lying on a bed) of the user [67].

Design implementation

Based on the requirements, the design of the eWrist focussed on lowering its physical profile and weight, enhancing wear comfort, and increasing usability of the fixation system for the exoskeleton, battery and electronics. To reduce weight on the distal part of the arm, the battery and electronics have been placed on the upper arm (upper arm module) while the actuated part of the exoskeleton is on the forearm and hand (forearm module) as depicted in Fig. 1a. Except for the motor, the motor drive, the worm drive and the Myo armband, all components are low-cost and widely available.

Fig. 1
Fig. 1 a The current version of the eWrist mounted on the right arm of a user. It is composed of three modules, namely, the forearm module, the upper arm module and the Myo armband. b The forearm module of the eWrist with two ratchet wheels (on the handle and on the forearm) to adjust the tightening tension. The locking hooks are equipped with two guiding magnets to ease the fixation. c The upper arm module of the eWrist and the four compliant gripping fingers that move inwards when the tightening wheel is turned. With the press of a button fixed to a ratchet (not shown on the picture) the tightening wheel unwinds and the fingers move outwards. d The restrained RoM from 77 in flexion to 77 in extension

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[Abstract + References] Home-Based Rehabilitation System for Stroke Survivors: A Clinical Evaluation

Abstract

Recently, a home-based rehabilitation system for stroke survivors (Baptista et al. Comput. Meth. Prog. Biomed. 176:111–120 2019), composed of two linked applications (one for the therapist and another one for the patient), has been introduced. The proposed system has been previously tested on healthy subjects. However, for a fair evaluation, it is necessary to carry out a clinical study considering stroke survivors. This work aims at evaluating the home-based rehabilitation system on 10 chronic post-stroke spastic patients. For this purpose, each patient carries out two exercises implying the motion of the spastic upper limb using the home-based rehabilitation system. The impact of the color-based 3D skeletal feedback, guiding the patients during the training, is studied. The Time Variable Replacement (TVR)-based average distance, as well as the average postural angle used in Baptista et al. (Comput. Meth. Prog. Biomed. 176:111–120 2019), are reported to compare the movement and the posture of the patient with and without showing the feedback proposals, respectively. Furthermore, three different questionnaires, specifically designed for this study, are used to evaluate the user experience of the therapist and the patients. Overall, the reported results suggest the relevance of the proposed system for home-based rehabilitation of stroke survivors.

References

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[Abstract] Preliminary Design of a Novel Teleoperation Interface for Home-based Upper Limb Rehabilitation

Abstract

With the increasing incidence of stroke, the demand for post-stroke rehabilitation is also increased. Various rehabilitation devices have been proposed to facilitate home-based rehabilitation and reduce the therapist’s workload. This paper presnets a novel teleoperation interface to allow the therapist in the hospital to guide the patient’s rehabilitation at home via TCP/IP communication. In order to achieve safe and comfortable home-based rehabilitation, the proposed teleoperation interface implements independent position and stiffness control to remotely guide the operation of the exoskeleton device worn on the patient. The preliminary experimental results showed that the proposed tele-rehabilitation was capable of providing effective power assistance and stiffness adjustment in real time under the guidance of the therapist.

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[Abstract + References] A Home-Based Adaptive Collaborative System for Stroke Patient Rehabilitation – Conference paper

Abstract

This paper describes research into the development of a collaborative home-based patient-therapist system for stroke patient rehabilitation. Our prototype system is designed so that home-based rehabilitation exercises are interactive and adapt to the progress of the patient. This way patients are encouraged to do the exercises most appropriate for their stage in the recovery process and can make the most of the time spent working on their rehabilitation. The system also keeps a record of patient progress that is communicated to the patient and medical professionals via mobile or personal-computer interfaces so they can work together towards a more effective overall plan for rehabilitation. This allows the physician to be better informed to make clinical decisions based on the progress of the patient. Results of early evaluations demonstrate the utility of our prototype system to provide users with a stimulating interactive experience as well as the systems potential to support medical experts to make more informed decisions relating to patient treatment. Results also indicate that patients feel more involved in their rehabilitation and that general communication between the medical experts and patients is improved.

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