[Abstract] Exploiting Virtual Reality to Design Exercises for the Recovery of Stroke Patients at Home

Abstract

Stroke affects approximately fifteen million people worldwide annually, with im- paired hand function being one of its most common effects. Hemiparetic post-stroke patients suffer a mild loss of strength involving one side of their body: though not fully debilitating, it still impacts their everyday life activities. To prevent mobility deterioration, patients must perform well-focused and repetitive exercises during chronic rehabilitation. Virtual Reality (VR) emerges as an interesting tool in this framework, offering the possibility of training and measuring the patient’s performances in ecologically valid, engaging, and challenging environments. In recent years, there has been an increasing diffusion of accessible head-mounted displays that enhance the sense of realism and immersion in a virtual scene. To explore the feasibility and efficacy of VR immersion and game mechanics in rehabilitation programs, a VR system that allows users to rehabilitate their motor skills in a home-based environment has been designed and tested considering standard measures related to usability, immersion, workload, and simulator sickness, and with the involvement of rehabilitation experts. The results demonstrate how users and experts have received the application positively, highlighting the potential of VR applications for the future development of home-based rehabilitation programs.

Source: https://re.public.polimi.it/handle/11311/1250780?mode=complete

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

Abstract

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: #NCT02780440

• Implications for Rehabilitation
• Home-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.

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[NEWS] Stroke rehab at home is near

Date:August 8, 2023

Source:University of Houston

Summary:The world of at-home stroke rehabilitation is growing near, after the development of an EEG headset that connects the brain of stroke patients to powered exoskeletons for rehabilitation purposes.

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FULL STORY

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The world of at-home stroke rehabilitation is growing near, incredible news for the 795,000 people in the United States who annually suffer a stroke. A new low cost, portable brain-computer interface that connects the brain of stroke patients to powered exoskeletons for rehabilitation purposes has been validated and tested at the University of Houston.

“We designed and validated a wireless, easy-to-use, mobile, dry-electrode headset for scalp electroencephalography (EEG) recordings for closed-loop brain-computer (BCI) interface and internet-of-things (IoT) applications,” reports professor Jose Luis Contreras-Vidal, Hugh Roy and Lillie Cranz Cullen Distinguished Professor of electrical and computer engineering, in the journal Sensors. Contreras-Vidal is an international pioneer in noninvasive brain-machine interfaces and robotic device inventions.

An EEG-based brain-computer interface (BCI) is a system that provides a pathway between the brain and external devices by interpreting EEG. In other words, the device reads your mind, interpreting the brain’s activity to initiate robotic movement. Brain-machine interfaces based on scalp EEG also have the potential to promote cortical plasticity following stroke, which has been shown to improve motor recovery outcomes. The adjustable headset, designed from commercial off-the-shelf components, can accommodate 90% of the population. There is a patent-pending on both the BCI algorithm and the self-positioning dry electrode bracket allowed for vertical self-positioning while parting the user’s hair to ensure contact of the electrode with the scalp.

“We used a multi-pronged approach that balanced interoperability, cost, portability, usability, form factor, reliability and closed-loop operation,” said Contreras-Vidal.

In the current prototype, five EEG electrodes were incorporated in the electrode bracket spanning the sensorimotor cortices and three skin sensors were included to measure eye movement and blinks. An inertial movement unit, measuring head motion, allows for a portable brain-body imaging system for BCI applications.

“Most commercial EEG-based BCI systems are tethered to immobile processing hardware or require complex programming or set-up, making them difficult to deploy outside of the clinic or laboratory without technical assistance or extensive training. A portable and wireless BCI system is highly preferred so it can be used outside lab in clinical and non-clinical mobile applications at home, work, or play,” said Contreras-Vidal.

The invention solves an array of needs.

“Current commercial EEG amplifiers and BCI headsets are prohibitively expensive, lack interoperability, or fail to provide a high signal quality or closed-loop operation, which are vital for BCI applications,” said Contreras-Vidal.

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[ARTICLE] High-Tech Home-Based Rehabilitation after Stroke: A Systematic Review and Meta-Analysis – Full Text

Abstract

(1) Background: To improve existing rehabilitation technologies, we conducted a systematic review and meta-analysis to identify the effect size of home-based rehabilitation using robotic, virtual reality, and game devices on physical function for stroke survivors. (2) Methods: Embase, PubMed, Cochrane Library, ProQuest, and CINAHL were used to search the randomized controlled trials that applied technologies via home-based rehabilitation, such as virtual reality, robot-assisted devices, and games. The effect size (Hedges’s g) of technology type and affected limb on physical function were calculated. (3) Results: Ten studies were included. The effect size of home-based rehabilitation in virtual reality had the greatest value (Hedges’s g, 0.850; 95% CI, 0.314–1.385), followed by robot-assisted devices (Hedges’s g, 0.120; 95% CI, 0.003–0.017) and games (Hedges’s g, −0.162; 95% CI, −0.036 to −0.534). The effect size was larger in the upper limbs (Hedges’s g, 0.287; 95% CI, 0.128–0.447) than in the lower limbs (Hedges’s g, −0.113; 95% CI, −0.547 to 0.321). (4) Conclusions: Virtual reality home rehabilitation was highly effective for physical function compared to other rehabilitation technologies. Interventions that consisted of a pre-structured and tailored program applied to the upper limbs were effective for physical function and psychological outcomes.

1. Introduction

Stroke, or cerebrovascular accident (CVA), is one of the most common causes of disability globally. The focus of stroke treatment is the restoration of blood flow to the brain and the control of secondary neurological damage [1]. Stroke has a negative impact not only on the individual’s physical health, but also on the psychological, social, and emotional health, depending on the severity, and it increases the burden on caregivers, including family members [1,2,3,4]. Rehabilitation is very important to this process. Intensive rehabilitation programs focus on functional recovery due to long-lasting physical impairments associated with stroke [1,2]. As an alternative to inpatient rehabilitation, home-based rehabilitation allows individuals to tailor their program to meet their preferences and schedules [3]. Although face-to-face home-based rehabilitation provides individualized services via physical consults from the rehabilitation team, it remains impersonal and a cost burden to both clinicians and patients [4]. With recent advances in technology and the increasing preference for virtual consultations due to the coronavirus disease 2019 (COVID-19), home-based virtual technologies are adapting to promote functional abilities [3,5]. Home-based rehabilitation support has been provided mainly through telecommunication devices such as videophones and telephones; however, virtual reality (VR) or robot-assisted devices (RD) have recently been introduced to facilitate home-based rehabilitation for stroke survivors [5]. These home-based technologies aim to improve patients’ physical function and internal motivation by encouraging their progress and goal attainment. Although several systematic reviews have evaluated the effect of new home-technologies on patient clinical outcomes, positive results were not always guaranteed [6,7,8]. For example, Maier et al. reported that the effect of VR on motor function recovery after stroke is unclear [7], and Hatem et al. reported that task-oriented RD therapy and VR were not recommended to enhance physical recovery in the subacute stage (<6 months) after stroke [6]. However, most of these conclusions were based on insufficient scientific data. Chen et al. also reviewed 31 articles that utilized a technology-based home rehabilitation service and defined 6 types of technologies (games, robotics, virtual reality, etc.), but they did not propose scientific parameters, such as effect size, for each technology [5].

A study also reviewed the effect of rehabilitation intervention according to the target limb. In a review by Hatem et al. that evaluated the effects of various rehabilitation interventions on upper limb function after stroke, RDs and VR were integrated as adjuvant therapies into stroke because of a lack of evidence even in mirror therapy [6]. Another limitation of this review was that they focused solely on upper limb function without focusing on the program delivery method or the effect on any other body part.

As such, the effectiveness of home-based rehabilitation may vary depending on the types of technology for rehabilitation, intervention contents, and target limb. Thus, this study aimed to identify the effect size of different technologies by systematically reviewing and analyzing studies that applied technology in home-based stroke rehabilitation programs. Our research questions are as follows:(a)

What are the effect sizes of VR, RDs, and games in home-based rehabilitation?(b)

Does the effect size differ depending on the type of technique applied?(c)

Does the effect size on the physical function of the stroke survivor differ depending on the target limb?

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[Abstract] Considerations for at-home upper-limb rehabilitation technology following stroke: Perspectives of stroke survivors and therapists – Request PDF

Abstract

Introduction This study investigated the needs of stroke survivors and therapists, and how they may contrast, for the design of robots for at-home post stroke rehabilitation therapy, in the Ontario, Canada, context. Methods Individual interviews were conducted with stroke survivors ( n = 10) and therapists ( n = 6). The transcripts were coded using thematic analysis inspired by the WHO International Classification of Functioning, Disability, and Health. Results Design recommendations, potential features, and barriers were identified from the interviews. Stroke survivors and therapists agreed on many of the needs for at-home robotic rehabilitation; however, stroke survivors had more insights into their home environment, barriers, and needs relating to technology, while therapists had more insights into therapy methodology and patient safety and interaction. Both groups felt a one-size-fits-all approach to rehabilitation robot design is inappropriate. Designs could address a broader range of impairments by incorporating household items and breaking activities down into their component motions. Designs should incorporate hand and wrist supports and activities. Designs should monitor trunk and shoulder motion and consider incorporating group activities. Conclusion While therapists can provide insight in the early stages of design of rehabilitation technology, stroke survivors’ perspectives are crucial to designing for the home environment.

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[Abstract] A Computer Game-based Tangible Upper Limb Rehabilitation Device

ABSTRACT

In order to regain the motor control of upper limbs, stroke patients should go through various exercises to resume finger, hand and arm functions. During such exercises, they need constant assistance, guidance and support from either therapists or caregivers. Due to the increase of aging population, the demand for technology support in home-based stroke recovery has rapidly increased in the last decade. This paper presents an interactive prototype designed to facilitate finger grasping, hand gripping and arm reaching exercises at home. It consists of a portable device with light, audio feedback and a computer game with two scenes and visual guidance. Preliminary usability testing in the community with elderly persons indicates that this device is easy to follow, and enjoyable to play. These trials explore the possibility and feasibility of implementing such tangible interactive training at home or in community rehab centers, inspiring us to improve such designs further to support active rehabilitation.

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[ORIGINAL REPORT] View of Compliance with Upper Limb Home-Based Exergaming Interventions for Stroke Patients: A Narrative Review

Background: Telerehabilitation and follow-up techniques have been developed in recent years to assess the effectiveness of diverse intervention programmes that include exergaming technologies. For patients with upper limb impairment after stroke, motion-gaming technologies can provide effective and amusing training. Beyond efficiency, professionals must analyse patient compliance with the system for self-use at home, because patients may or may not independently perform the exercises prescribed by the therapist. Questions on the sustainable use of this type of home exercise also arise.

Objective: This review examines user compliance with exercise programmes, measured according to the training rate (percentage of prescribed sessions and minutes completed) and completion rate (number of drop-outs and discontinued interventions) reported or calculable according to the data collected.

Results and discussion: Rates of compliance with training were relatively high. No group effect on compliance was found. Drop-out and discontinued intervention rates were either due to external causes or directly related to the technologies. Some studies have reported the use of supervision, most of them through home visits and remote support. Few studies performed long-term follow-up, which could provide information to help broaden practices. This narrative review considers how this field of research may evolve in the future.

LAY ABSTRACT

The use of video games in hospitals as a rehabilitation tool in neurology is developing, particularly for stroke victims. For patients with arm problems, it can be effective and fun to use gamified systems. When the patient goes home, they must continue their rehabilitation in order to continue to progress or maintain their skills. However, performing exercises alone at home raises questions about patients’ compliance with the exercises prescribed by their therapists. Do patients complete the prescribed sessions? Are there occasional or permanent interruptions? This narrative review attempts to address these questions. The review also examines the obstacles that might hinder the use of these technologies and the facilitators that may help compliance.

Telerehabilitation offers an alternative rehabilitation technique through the delivery of rehabilitation and habilitation services via information and communication technologies (ICTs) (1, 2). Telerehabilitation is a useful approach in outpatient rehabilitation, especially for post-stroke patients (3). Stroke was the second-leading cause of death and third-leading cause of death and disability combined worldwide in 2019 (4). Stroke is highly prevalent among older patients, many of whom have underlying health issues (e.g. diabetes, hypertension, and cardiovascular disease). Upper extremity paralysis is a predominant impairment after stroke, with a recovery rate of 10–20% (5), affecting independence and quality of life (6). This reflects the importance of post-hospital discharge support programmes. Telerehabilitation is one possible approach in outpatient stroke rehabilitation, with follow-up at home.

Exergaming, otherwise known as exercise-based games (e.g. virtual reality and interactive video-game interventions) is a relevant alternative home-based rehabilitation for persons with neurological diseases. The effectiveness of these interventions has been shown to be at least equivalent to conventional therapy or usual care (7). Most studies have focused on assessing the effectiveness of the technologies, but patient compliance with these technologies is under-explored. Even if the technology can be adapted technically or physiologically, it remains necessary for the patient to want to use it; therefore, effective implementation for self-use at home depends on patient compliance.

Medical compliance was defined in the late 1970s as “the extent to which the patient’s behavior in terms of taking medications, following diets, or executing other lifestyle changes coincides with medical or health advice” (8). Exercise compliance is defined as “a person’s compliance with a prescribed or self-prescribed fitness program” (9). The terms compliance, adherence, and concordance are often used interchangeably (10). The term compliance is used throughout this narrative review as an indication of positive patient behaviour in following an exercise programme. Many people do not feel motivated to engage in new habits, including exercise. In 2013, a meta-analysis showed that approximately 21% of people did not intend to take up physical activity, while 36% intended to, but found changing their sedentary behaviour difficult (11). Training is often limited by a lack of motivation, which can be the main reported reason for non-adherence with home exercise by individuals with chronic stroke (12). Designing optimal rehabilitation treatment programmes for stroke patients requires an understanding of “What” is the content of the treatment, “How much” treatment is required, and “When” treatment is best delivered (13).

This narrative review assesses patient compliance according to the type of upper limb technology used and the home implementation parameters.

GAME-BASED SYSTEMS IN THE HOME-BASED SETTING

Exergaming is defined as the integration of physical activity into a video-game environment that requires active body movements to control the game (14). The emergence of commercial video-game systems, coupled with handheld controllers and motion-capture devices, has facilitated the use of computer games for neurorehabilitation. These technologies have the potential to be effective for increasing upper limb capacities (15–18). Game-based systems may offer a motivational exercise environment that encourages continued use. Health professionals and participants have reported high levels of satisfaction and acceptance of telerehabilitation interventions (5). Piron et al. (2008) showed that post-stroke patients with arm motor impairments assigned to the home-based virtual reality group were able to engage in therapy at home through a user-friendly system, and the videoconferencing system ensured a good relationship between the patient and the remote therapist (19). Their study was based on the patient’s degree of satisfaction, an important indicator of the efficacy of the therapeutic intervention, which improves the patient’s motivation to engage in rehabilitation.

A range of commercial gaming systems are described in the literature for home use: Kinect™ (Microsoft Corporation; Redmond WA, USA) (30, 32, 34, 43), Wii™ (Nintendo, Japon) (25–28), Vive™ (HTC, Taïwan) (29), PlayStation® 3 Eye Move controller (Sony, Japon) (26), Leap Motion controller (Ultraleap, USA) (30) (Table I). These devices are mostly associated with custom games and other specific rehabilitation devices, such as robotic devices, specific controllers, and passive arm support (e.g. TheraBot system (Rehabilitation Robotics and Research and Design Lab, Milwaukee, WI, USA) (31), SaeboMAS (Saebo Inc., Charlotte NC, USA) with SCRIPT dynamic wrist and hand orthosis sensor (32), HandinMind (HiM) system (33) (Hocoma AG, Switzerland), P5 Glove (Essential Reality Inc; NY, USA) (24), Armeo®Senso (Hocoma AG, Switzerland) (34), BrightBrainer™ Grasp (Bright Cloud International, NJ, USA) (29), Myo Band (n.a) (26), MusicGlove (FlintRehab, CA, USA) (35), CyWee Z controller (CyWee Inc., Taiwan) (36) and passive arm support (30)) (Table I).

Author, year	Design Methods Data collection	Participants	Technology	Implementation parameters (number of sessions, frequency, and length)	Home training (min)	Drop out	Discontinued intervention
Brokaw et al. (43)	Pilot evaluation of the usability and utility in the home Qualitative Interview	1 stroke patient	Computer screen, Kinect™ (Microsoft Corporation; Redmond WA, USA), 5 custom games	19 sessions 30 min, 5 days/week, for 4 weeks	NR	No	1 session hardware not used final 3 training sessions
Burdea et al. (29)	Feasibility study Mixed Survey + training	7 chronic post-stroke patients 7 caregivers	BrightBrainer™ (Bright Cloud International, NJ, USA) computer, Vive™ (HTC, Taïwan) and BrightBrainer Grasp controllers, custom games, Automatic electrical meter	20 sessions wk 1 20 min wk 2 25 min wk 3 30 min wk 4 40 min 5 days/week, 4 weeks	605 min	1 screening failure (low MOCA score)	NR
Chen et al. (26)	Qualitative study in a randomized trial Qualitative semi-structured interviews	13 stroke patients	Computer, Myo Band, Wiimote™ (Nintendo, Japon) in a pistol-shaped holder, Power Mate, PlayStation® 3 Eye Move controller (Sony, Japon), Joystick, Logitech Trackpad, real-time video guidance	36 sessions 70 min at a fixed time every day 6 days per week, over 6–8 weeks	NR	No	NR
Dodakian et al. (35)	Pilot study Quantitative Survey	12 stroke patients	Laptop, wrist accelerometer sensor, MusicGlove (FlintRehab, CA, USA), 18 games, videoconference	1 structured hour + 1 h of free play, for 28 days (2 × 14-day separated by a 1–3-week break)	Active time (games+exercises): 60 ± 10 min/d, including a mean of 22 ± 24 min/d of free play. Total time (active time + education questions, measuring blood pressure, reading game instructions, donning devices, and taking breaks between tasks): 182 ± 61 min/d.	No	1 not completed 4 sessions (fatigue) 1 not completed 1 session (hardware malfunction) 1 missed 2 complete sessions (other medical appointments)
Fluet et al. (30)	A Feasibility and pilot study – comparison Mixed Survey + training	11 stroke patients: 5 enhanced motivation (EM) group + 6 unenhanced control (UC) group	Leap Motion controller (Ultraleap, USA) passive arm support, custom-designed simulations	As much as possible, but at least 20 min, daily for 12 weeks	> 400 sessions. Enhanced motivation group: 95±95 min per week (range 40–276 min) Unenhanced control group: 35 ± 31 min per week (range 3–93min)	NR	NR
King et al. (36)	Case series (after a trial of 10 sessions of bilateral therapy using VR) (Hijmans et al.2011) Mixed Survey + Training	3 patients with chronic stroke	Computer screen, CyWee Z controller (CyWee Inc., Taiwan) games	Chose when and for how long for in each session, for no longer than 90 min on any given day Each game at least once, after free to choose the proportion of time on any games for 8 weeks	≥ 35 min per session ≥ 4.5 times per week ≥ 33.5 hcontinued for between 55 and 61 days at home	No	Diary: mean number total of days missed: 11.66
McNulty et al. (25)	a randomized controlled trial Mixed Survey + structured interview + training	41 stroke patients (21 + 20)	Wiimote™ (Nintendo, Japon) Wii Sports™ games	10 sessions 60 min weekdays, progressively increasing, for 14 days follow-up 6 months	Wii-based Movement Therapy (WMT): 1,188 min modified constraint-induced movement therapy (mCIMT): 1,194 min. Completion rates 105.7 (93.6–114.7)% (WMT) and 101.0 (87.6–108.1)% (mCIMT)	2 EG (withdrew+death) 1 CG (unrelated medical condition)	NR
Nijenhuis et al. (32)	Pilot randomized controlled trial Mixed Survey + semi-structured interview + training	20 stroke patients (10 + 10)	Computer, SaeboMAS (Saebo Inc., Charlotte NC, USA) SCRIPT dynamic wrist and hand orthosis sensor, games	36 sessions at least 30 min per day, 6 days a week, for 6 weeks follow-up 2 months	CG: 189 (143–266) min per week EG: 118 (51–176) min per week ranging from 13 to 423 min per week	1 EG (shoulder pain due to external causes)	NR
Sivan et al (49)	Feasibility study Qualitative semi-structured interview	17 (9 prototype) patients + 7 therapists	Computer screen, powered joystick, controlled assistance, 8 games	8 weeks	NR	NR	NR
Standen et al. (27)	Prospective cohort study plus qualitative analysis Mixed Semi-structured interview + training	29 stroke patients, including 17 in the qualitative study	PC, Virtual glove, Wiimote™ (Nintendo, Japon), 3 custom games	3 times a day for periods of no more than 20 min, for 8 weeks	Percentage of the duration of use ranged from 1.46 to 70.6 percentage of days used ranged from 10% to 100%	Allocation: 4 EG (family issues, not interested, arm pain, severe aphasia) Follow-up: 1 CG (measures onerous) + 3 EG (illness, ill family member, going on holiday)	NR
Thielbar et al. (21)	Randomized trial – crossover, interventional study Mixed Survey + Training	20 chronic post-stroke patients (10 in the FSU group and 10 in the FMU group)	Computer, Kinect™ Microsoft Corporation; Redmond WA, USA) wireless mouse. 3 custom exercises, voice communication, remote central server, custom Google Cloud Virtual Machine	8 sessions 4 sessions of 1 h each week, for 4 weeks: 2 weeks with multi-user (MU) + 2 single-user (SU) version	For the SU mode, FSU group: 30.2 ± 10.8 min and FMU: 39.9 ± 12.8 min For the MU mode, the FSU and FMU groups had similar times	1 (medical reasons) 1 FMU group (declined participation)	MU mode: 18 of 20 subjects participated in all 8 sessions, and all 20 subjects participated in at least 7 sessions SU mode: only 15 of 20 subjects participated in all 8 sessions, and 16 of 20 participated in at least 7 sessions
Wingham et al. (28)	Pragmatic multi-centre RCT with a qualitative study and health economics analysis Qualitative semi-structured interview	19 stroke patients 10 caregivers	Television, Wii console, Wii games	For up to 45 min daily for 6 weeks followed up at 6 weeks and 6 months	EG: 37 min (range 4–108 min) CG: 32 min (range 4–63 min)	1 (timetable)	NR
Wittmann et al. (34)	Feasibility study Mixed Structured patient interview + training	11 stroke patients	Armeo®Senso (Hocoma, Switzerland) = wearable inertial measurement units (IMU)	As often as possible for 6 weeks	26.5 ± 11.5 (min 8, max 41) days out of 42 days duration per week: 137 ± 120 min (min 15, max 357) training sessions on 4.4 days per week training (gaming) duration per session: 30 ± 16 min (min 11, max 56)	NR	NR
NR: non-recorded; EG: experimental group; CG: control group; EM: enhanced motivation group; UC: unenhanced control group; WMT: Wii-based movement therapy; mCIMT: modified constraint-induced movement therapy; SU: single user; MU: multi-user, wk: weeks; min: minimum; max: maximum; MoCA: montreal cognitive assessment.

Some studies included real-time audio or video systems (30, 31, 39, 43, 47). The exergames used in the studies were specific or non-specific systems for upper-limb stroke rehabilitation. Devices can be used alone or in combination with other technologies (e.g. exoskeleton, robotics, exogenous stimulation, virtual reality headsets, and augmented reality), potentially further improving recovery. It is of interest to determine whether combinations can have a positive impact on compliance. For example, in the REINVENT platform (37), researchers combined the principles of action observation in head-mounted virtual reality with brain-computer interface (BCI) neurofeedback for stroke rehabilitation to try to elicit optimal rehabilitation gains. It would be of interest to assess the relevance of this on functional activities and in different settings (e.g. laboratory, clinic, home). As reported by Perrochon et al. (2019), future studies in the home should include the multiple observations reported in the literature to ensure an optimal exergaming design (7, 38).

HOME EXERCISE REGIMEN

Several systematic reviews have indicated that intensive treatment is favoured, but there is no consensus on the optimum amount, intensity, distribution, or duration of therapy (39). Across a large number of studies, the key elements of task-specific training are repeated, challenging the practice of functional, goal-oriented activities (40–42). Motion-tracking systems provide real-time feedback regarding execution of task-specific exercises, but it is unclear which is the most efficient training. To our knowledge, there are no guidelines regarding the appropriate maximum duration of research and clinical sessions to maintain compliance. Dose, frequency, and duration scheduling of home-based therapy are shown in Table I.

The overall dose ranged from 20 min (29) to 120 min per day (1 h structured activity and 1 h free play) (35). The recommended time increased stepwise each week for 1 study (29), whereas another progressively increased the time over 10 consecutive weekdays (25). Three studies did not give the number of expected min per day (30, 34, 36). Three studies indicated a time limit not to be exceeded; users played for as long as they wanted in a session and whenever they wanted, but for no longer than 90 min on any given day (36); 3 times per day for periods of no more than 20 min (27); or for up to 45 min daily (28). Conversely, another study indicated a minimum time limit requirement of 20 min daily (30). Time of day can be defined to accommodate the necessary appointments with therapists (21, 26). The current review observed variability in the prescriptions: studies proposing 30 min per day were considered as sub-therapeutic. In contrast, planning 1–2 h per day of task time and assessing repetitions and intensity accurately were recommended (13).

The number of sessions ranged from 8 (21) to 36 (26, 32). Six studies did not specify the number of expected sessions ((27, 28, 30, 34–36). The number of days per week were set at 5 (29, 43), 6 (26, 32) or 7 (28, 35). Hence, the sessions were discontinuous or continuous, depending on the study.

The most often used training duration in the studies was 6 weeks (26, 28, 32, 34, 36). Other studies had a total intervention duration ranging from 14 days (25) to 12 weeks (30). Only 1 study planned an interruption after 14 days of 1–3 weeks halfway through the intervention (35). They explained that 14 days was selected based on the success of the EXCITE trial of constraint-induced therapy, which showed benefits when making daily demands on patients for 14 days (44). Only 3 studies proposed follow-up to assess the persistence of improvements in motor function. They did not indicate any information on long-term engagement.

COMPLIANCE ASSESSMENT

Training compliance rate

Some authors referred to the training rate to assess compliance quantitatively. The ratio of the quantity of training performed by the patient to the quantity prescribed by the therapist was reported or calculated. Some authors considered the total training time, in minutes, performed by the study subject, the mean number of sessions per week, and the mean minutes per session for home-based interventions. These data can be compared with the authors’ recommendations.

Certain studies calculated high compliance rate of approximately 96% (29). Other authors compared groups, for example, compliance was very high (99%) for the multi-user mode and 89% for the simple-user mode, suggesting that the training mode can affect the compliance (21). More, the change in the difficulty and complexity showed a greater increase in training time per session than the control group (30). Some other studies have a compliance rate of over 100, taking 100% as the time prescribed by the therapist. Indeed, some studies allow patients to do more exercises if they wish following their prescribed time (30, 32). For example, the completion rate was 105.7% (93.6–114.7%) for the Wii-based movement therapy and 101.0% (87.6–108.1%) for the control group (median, interquartile range) (25). Conversely, a high compliance rate was found for the control group (105%), but not for the experimental group using computerized gaming exercises (65.6%) (32).

A few studies reported the number of repetitions performed during the intervention (29, 34, 35). However, with few comparative data, we chose not to report the data in this review.

Participants in the study by Nijenhuis et al. (32) recorded the frequency and duration of training in a diary to assess user compliance with training duration and motivation. King et al. (36) used the same methods to assess patient engagement quantitatively, using diaries to record the occurrence and duration of the intervention.

Attrition rate

The attrition rate is calculated as the number of drop-outs and discontinued interventions. Within eHealth interventions, the exponential decrease in adherence has been described as the “Law of Attrition” (45). It is essential to consider the main causes of the rate and to set up tools to reduce the level of attrition as much as possible. Dropping out of therapy is an implicit marker of dissatisfaction or unacceptability. Variability in acceptable discontinued intervention/drop-out rates was found in the literature, ranging from 5%, to 20%, and 30% for follow-up of more than 1 year (46).

Literature results showed a high attrition rate for the home-based setting, although the drop-out rate was higher for the experimental group than for the control group (25, 27, 32). The completion rate was not described in all studies. However, among the studies that evaluated the completion rate, variable results were found. For example, a 94.7% rate for intervention completion was reported by Brokaw et al. (43), with only 1 missed session and a 97.9% rate was described by Dodakian et al. (35) with 3 patients not completing or missing sessions. King et al. (36) provided the number of days of intervention over the total intervention period for each subject, recorded by the participants in diaries, and reported a rate of 79.9%. Thielbar et al. (21) compared the training attrition rate between groups: in the multi-user (MU) mode, 90% of subjects participated in all 8 sessions, and 100% participated in at least 7 sessions. However, in the single-user (SU) mode, only 75% of subjects participated in all 8 sessions and 80% participated in at least 7 sessions (21).

BARRIERS TO COMPLIANCE

Non-compliance was intentional or non-intentional. Some factors were due to internal factors (no interest, pain, fatigue, severe aphasia, seizure, illness, death, etc.) and others to external factors (family issues, ill family member, holidays, schedule). This led to limited compliance, and patients either dropped out or discontinued the interventions. Some non-compliance factors were correlated with technical issues: Brokaw et al. (43) reported that participants completed 18 of the planned 19 sessions, but hardware issues prevented participants from using the system for the final 3 training sessions; Some studies reported technical issues with the hardware (26, 29, 35, 43, 49), the software (35), communication reliability causing storage data problems (29), the home setting (26, 29, 49), unsuitability for use with spastic hands (29), and time constraints (26). These aspects did not necessarily stop the patients from participating in the study. As reported by Perrochon et al. (2019), the rate of drop-out and discontinued interventions were due either to external causes or directly related to the technologies (7). Dodakian et al. (35) produced a summary document of the issues, solutions, and lessons learned for future telerehabilitation studies. This initiative is relevant for future perspectives. As Ong et al. (2018) stated, identifying manipulable aspects of treatment that reduce the probability of drop-out can guide the development of more acceptable interventions (47).

FACILITATORS OF COMPLIANCE

Some authors proposed a familiarization stage with the device before home use. Some studies provided laboratory familiarization before home use: 1 session (43), a brief 2- or 3-day orientation (21), and 10 sessions (36). Familiarization directly at home was also prescribed: 1 session (29) and 2 sessions (43). Other studies established an initial visit for training purposes (27, 30). These sessions equipped participants with the skills to continue the programme safely and independently at home.

Other means were established to carry out the intervention. One study supplied an instruction manual at the beginning (frequently asked questions and tips) (27), whereas another used a transfer package in each session including different forms to emphasize patient safety, monitor home practice, improve handling and compliance, and provide a forum for patient-centred goal-setting and problem-solving (25). This allows for self-care before calling in the therapists.

However, remote assistance was necessary in most of the studies for which it was made available. Technical issues were expected during studies with this type of technology. Some systems can be used as remotely monitored telerehabilitation; for example, some studies used only telephone calls while others used videoconferencing, education videos, web-based chats, or virtual reality systems (48). Clinicians can propose appropriate responses by adapting and personalizing the planned rehabilitation activities and offering technical assistance when needed. It is important to verify whether the use of telerehabilitation systems can improve patient engagement by conducting their rehabilitation training at home in a safe environment.

Four studies supervised the interventions by combining home visits and remote support via phone calls (27, 29, 30, 43), whereas 1 study relied only on home visits (32). Two studies used videoconferencing and remote support (26, 35) and 1 study scheduled remote appointments using the remote therapist-patient systems and telephone support (21). Remote access to data on participants’ playing performance can be used to verify compliance with the protocol (29). It can be a way to automatically inform the researcher if the data has not been uploaded for three consecutive days (29). The first home visits included a time dedicated to installation and explanations with patients and possibly caregivers. Some studies did not offer supervision (34, 36, 49).

Furthermore, some authors requested patient feedback. Participants in the study by Chen et al. (26) specified having received support following minor technical issues. Participants and caregivers in the study by Wingham et al. (28) said they felt reassured and supported by the weekly phone call, but also appreciated the social connection.

Dodakian et al. (35) measured the assistance given by phone during the study. The authors supposed that the decrease in assistance required over time might be due to patient familiarity with the system and improved performance of the study team.

Videoconferencing allowed therapists to observe patient performance, answer questions, review the treatment plan, and, on select days, perform brief study assessments (26). In the same study, daily 30-min half-therapy sessions were supervised by videoconference, followed by 40 min during which the patient was alone. Dodakian et al. (2017) proposed 3 videoconferences per week, focusing on the prior week’s activities, followed by a structured interview including specific inquiries on pain, adverse events, and the telerehabilitation system performance. The authors explained that providing feedback and encouragement could increase motivation, according to the standard of care (35). Johnson et al. (2011) described simple encouragement provided through video and audio feedback via a robot assistant (31). In addition to the aspects of communication with the user and monitoring of progress, it could also allow for remote monitoring of the the user’s position when using the device (49).

Fluet et al. (30) described modest motivational enhancements and discussed areas for increasing the training time per session. One suggestion was that supervision in the form of email and text message reminders of weekly tasks could increase the number of training sessions.

It is important to make the games interesting and stimulating to increase the use of the device (49). Integration of the multi-player mode within a game-based task could also be a factor in increasing compliance (21, 49).

DISCUSSION

Compliance behaviour is complex, requiring an analysis based on theoretical models. Over the years, specific theoretical models for studying compliance have been described. In the Health Belief Model (HBM), compliance is determined by the knowledge and attitudes of the patient (50). There are 4 essential areas in the development of compliant behaviour: perceived susceptibility; perceived severity; perceived benefits; and perceived barriers. More recent forms of the HBM emphasized 2 other factors in the decision to engage in a behaviour: (i) self-efficacy, which is the patient’s belief that he or she is capable of taking the recommended action; and (ii) action cues, which are aids that teach or remind the patient of the recommended action (51). Designing a novel technology for stroke patients involves a deep understanding of the persons who use the system and perform the activity, and the context in which that activity takes place. User expectations and needs must be understood, as must their motivations, and previous experiences (52). The context of use is also a key element to explore at this pre-implementation stage and to evaluate at the post-implementation stage. The architectural, material, and human environment must be considered with regard to use of the system in the patient’s home. Evaluating user experience with interactions and the use of the system is relevant to obtain patient reactions in post-task interview questions (53), and in particular, in terms of compliance with use and engagement.

Most researchers used an off-the-shelf system (i.e. a commercial system) as a primary tool and combined it with elements or games adapted to neuro-rehabilitation. According to Tamayo-Serrano et al. (2018), low-cost solutions are expected to promote the adoption of in-home rehabilitation systems by patients and health organizations (54). To be able to assess cost-effectiveness, quantified cost and time data must be considered. For example, Lloréns et al. (55) reported the cost of telerehabilitation and in-clinic programmes. Costs were reported in terms of human resources (time spent on assistance and guidance during the intervention, progress monitoring, and troubleshooting), round trips to the neurorehabilitation unit, and instrumentation (laptop, Kinect™, and internet access) (55). The cost of the clinical instrumentation was not considered, but this would have provided additional information for comparison. More transparency on the costs incurred would be useful for future studies. Table II summarizes the current literature on compliance.

Topics	Definitions	Major findings
Game-based systems in home settings	Exergaming: the integration of physical activity into a video game environment that requires active body movements to control the game	Most researchers used an off-the-shelf system (i.e. commercial system) as a primary tool with added elements or games adapted to neuro-rehabilitation
Home exercise regimen	Amount, intensity, distribution, or duration of treatment recommended by therapists	Variability in current prescriptions. 30 min per day is considered sub-therapeutic. Recommended to plan 1–2 h per day of task time and to assess repetitions and intensity accurately
Training compliance rate	Ratio between quantity of training completed by the patient and quantity previously prescribed by the therapist	Patients generally follow the prescription and some even go further by continuing to train if allowed. There is no group effect on compliance (it may be greater for the experimental group than the control group, or vice versa)
Attrition rate	Drop-out: percentage of subjects failing to complete a study Discontinued intervention: percentage of sessions failing to complete	High attrition rate for the home-based setting, although the drop-out rate was higher for the experimental group than for the control group The rate of discontinuation of intervention is lower for the multi-user (MU) mode than the single-user (SU) mode
Compliance barriers	Causes of non-compliance	Internal factors: no interest, pain, fatigue, severe aphasia, seizure, illness, death External factors: family issues, ill family member, holidays, timetable Technical adverse events: hardware, software, communication reliability causing storage data problems, home environment, unsuitability to use with spastic hands, time constraints
Compliance facilitators	Options for promoting exercise compliance	Explanations given by the therapist before the intervention Familiarization stage Notices/instructions available Remote or in-person assistance Remote or in-person monitoring Forum for patient-centred goal-setting and problem-solving Logbooks and diaries Multi-player mode

CONCLUSION AND PERSPECTIVES

This narrative review identified current practices for user involvement in the development of stroke-patient decisions on home-based gaming technology. This review studied compliance with technologies adapted to post-stroke rehabilitation. The literature on the subject is recent. Heterogeneity is found on the type of technologies, the intervention regime, and the supervision, making it difficult to draw conclusions on compliance. More robust studies are needed to provide additional data.

In general, home-based gaming therapies are well received by patients and no significant problems occur. Additional experimental studies are required to understand which determinants, intrinsic to devices, impact the user’s compliance. Further research into the conditions for the personalized specification of the technological devices, developed in co-construction with the user, would be useful. Current studies focus on short-term evaluations; however, a long-term view is necessary to assess user compliance for high-ecological validity. Future studies should investigate how emerging technologies enable long-term use and the transfer of the acquired knowledge to everyday life, and should identify resources and assess the suitability of the system’s settings based on the best situation for home use.

ACKNOWLEDGEMENTS

The authors thank Hugo Landais and “La Fondation de l’Avenir pour la recherche médicale appliquée” (Paris, France) and the European Institute of Technology (EIT Health) for their scientific insights and unyielding support.

Authors’ declaration of authorship contribution

All those designated as authors meet the International Committee of Medical Journal Editors (ICMJE) requirements for authorship.

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[Abstract] Robustness of Hand Motor Function Evaluation System on Home Rehabilitation Device

Abstract:

Continuous hand rehabilitation at home is important for hemiplegic patient because the hand is difficult to recover. Nevertheless, a patient cannot sufficiently receive rehabilitation compared with in clinic and it may lead to worsening condition. In this study, we try to solve problems by developing hand rehabilitation device which enables patient to do self-rehabilitation. To realize the device, evaluation system for feedback is important. We have also proposed the evaluation system by calculating dissimilarity with healthy subject’s finger movement which is measured by pressure sensors. Although our system shows good relationship with patients who has various condition, it is unclear whether the system has same tendency even hardware is modified. Therefore, we experiment the robustness of evaluation system by using 2 devices. As a result, evaluation system does not depend on hardware modification.

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[ARTICLE] Acceptability and deliverability of an auditory rhythmical cueing (ARC) training programme for use at home and outdoors to improve gait and physical activity post-stroke – Full Text

Abstract

Background

Although laboratory studies demonstrate that training programmes using auditory rhythmical cueing (ARC) may improve gait post-stroke, few studies have evaluated this intervention in the home and outdoors where deployment may be more appropriate. This manuscript reports stakeholder refinement of an ARC gait and balance training programme for use at home and outdoors, and a study which assessed acceptability and deliverability of this programme.

Methods

Programme design and content were refined during stakeholder workshops involving physiotherapists and stroke survivors. A two-group acceptability and deliverability study was then undertaken. Twelve patients post-stroke with a gait related mobility impairment received either the ARC gait and balance training programme or the gait and balance training programme without ARC. Programme provider written notes, participant exercise and fall diaries, adverse event monitoring and feedback questionnaires captured data about deliverability, safety and acceptability of the programmes.

Results

The training programme consisted of 18 sessions (six supervised, 12 self-managed) of exercises and ARC delivered by a low-cost commercially available metronome. All 12 participants completed the six supervised sessions and 10/12 completed the 12 self-managed sessions. Provider and participant session written records and feedback questionnaires confirmed programme deliverability and acceptability.

Conclusion

An ARC gait and balance training programme refined by key stakeholders was feasible to deliver and acceptable to participants and providers.

What’s already known about this topic

Auditory rhythmical cueing improves walking following stroke when delivered in the laboratory or clinical settings. Limited research exists, however, on the use of ARC in the home and outdoors where deployment may be more appropriate.What does the study add (one or two sentences)

The study demonstrated that an ARC gait and balance training programme can be delivered in the home and outdoors. The programme was acceptable to both stroke survivors and therapists.

Background

Although up to 80% of stroke survivors may eventually recover their ability to walk short distances [1], many do not achieve the locomotor capacity necessary for ‘real-world’ walking [2]. Gait impairments can limit household and outdoor ambulation post-stroke [3] and are associated with increased dependency in activities of daily living and reduced quality of life [4]. Typical impairments commonly observed post-stroke include reduced walking speed, decreased stride length/cadence and increased temporal asymmetry [5, 6]. The ability to walk safely and unsupervised around the home and outdoors is fundamental to independent living and as such is an important topic in stroke rehabilitation [7]. Stroke survivors view the ability to walk safely and effectively outdoors as a top priority [8], but unfortunately this is unachievable for many who as a result are confined to home [7, 9].

A potential method of enhancing the efficacy of gait rehabilitation post-stroke is auditory rhythmical cueing (ARC). ARC provides auditory feedback to target gait and physical activity. A metronome beat or music is delivered during exercise training in order to normalise and entrain stepping [10]. The efficacy of ARC has been well established in Parkinson’s disease over the last 20 years [11], and this intervention has more recently been utilised in stroke.

ARC gait training may confer benefits including increased practice of walking which is a recognized key component in recovery post-stroke [10, 12]. A recent systematic review [13] reported significant improvements in gait velocity, cadence and stride length following an ARC intervention compared to control groups receiving other types of rehabilitation. Whilst this suggests promise for ARC as a tool for improving gait, much of this work on ARC in stroke was ward or laboratory based which limits application of findings to ‘real world’ walking. Real world walking requires the ability to change speed and direction, for example, when walking in crowds or across roads, endurance to enable participation in community settings, and the ability to negotiate different terrains during different weather or ambient conditions [14]. Rather than using ARC to target aspects of efficient and effective walking, the studies in the review predominantly targeted laboratory based overground indoor walking in a straight line. The studies included in the review were also limited by size, bias (e.g., only 25% of the studies had blinded outcome assessments) and a large proportion were conducted over 10 years ago.

One recent study has examined the use of ARC within the home for stroke survivors [15]. This small pilot study (n = 12) evaluated ARC delivered whilst the stroke survivors stepped on the spot and reported that this programme was feasible, well-tolerated and improved walking ability. Whilst this is promising early data to support the use of ARC in the home, bigger studies and those which include different aspects of walking e.g., turning, and outdoor walking are needed to evaluate this treatment further.

To inform the design of a pilot randomised controlled trial of an ARC gait and balance training programme for use by stroke survivors in the home and outdoors, we undertook the work reported in this manuscript which aimed to refine a prototype ARC programme and then to assess whether the programme was acceptable and deliverable.[…]

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[ARTICLE] Technologies to improve the participation of stroke patients in their home environment

Abstract

Purpose

To identify possible technological solutions that can contribute to stroke patients’ participation at home.

Methods

In this qualitative case study, data on factors that negatively influenced participation at home were collected via semi-structured interviews with stroke patients (n = 6). Additionally, data on possible technologies to improve this participation were collected via a group interview with experts (n = 4). The domains “cognition, mobility, self-care, and getting along” (International Classification of Functioning, Disability and Health) guided the data collection and interpretation; open, axial and selective coding was part of the analysis.

Results

Patients reported 21 factors negatively influencing participation at home, including psychological, cognitive, and physical factors. Experts suggested technological solutions regarding these factors to increase participation of stroke patients; digital assistants, apps, and virtual reality were frequently mentioned. To facilitate the use of these technologies, experts indicated the importance of involving patients in their design. They also suggested that rehabilitation specialists and family members could support the uptake and use of technologies.

Conclusions

Various technologies were identified by experts as having the potential to improve the participation of stroke patients in their homes. Future research may study the influence of these technologies on the actual participation of stroke patients at home.

• Implications for rehabilitation
• The identified technological solutions can support rehabilitation specialists in guiding stroke patients towards technologies that can support a patient’s participation at home.
• Rehabilitation specialists can be champions in introducing, recommending and promoting technologies to stroke patients and their families, as well as in training them to use technologies.
• Virtual reality as a technology can be part of rehabilitation, not only to train stroke patients in daily life activities but also to increase empathy and understanding in caregivers and carers on stroke impairments.
• Rehabilitation specialists can recommend technologies integrated in daily life and presented as general consumer goods; stroke patients are more likely to adopt these kind of technologies.

Introduction

With rates of survival increasing throughout the years, stroke has become one of the leading causes of adult disability [1]. The dysfunctions that result from stroke can be divided into neurological (paresis, sensational, hemianopia), neuropsychological (aphasia, neglect, apraxia), and psychological (behaviour, mood, personality) [2]. Despite undergoing rehabilitation in the early post-stroke phases, survivors often experience difficulties in participating in their daily activities at home [3]. An experiential gap between the roles they wish to play and the roles they are able to play in their home environment is common [4]. Technologies may contribute to bridging this gap by helping to increase their participation.

Various technologies aim to increase function and activity in stroke patients. The use of technologies during stroke rehabilitation in a clinical setting, i.e., prior to returning home, has been well researched. Many studies describe the use of technology related to body function, for instance, of the upper [5] and lower limb [6]. Hence, there has been a focus on initial improvements in specific body functions and demarcated activities, like walking, and, to a lesser extent, focusing on improved participation in a more demanding home environment. Other technologies used and valued by stroke patients have a signalling or reassuring function, e.g., smart home technology that monitors users’ activity and alerts a contact person if a change in activity level is observed [7]. In patients with other health problems, the actual use of technologies at home has been one of the main study topics. For example, multiple studies support the potential of technology as a tool to increase independent living for people with dementia [8, 9]. In people with a disability, the use of technologies such as telephones or (changes in) lighting reduces functional problems and increases the ability to gain or maintain independence [10]. Additionally, in patients with amyotrophic lateral sclerosis, low-technology devices such as speaker phones and sound- or voice-activated environmental controls were perceived as particularly useful, and patients reported high levels of satisfaction [11]. These findings indicate that the use of technologies can positively influence the lives of people with health problems.

Regarding stroke patients’ participation at home, evidence of the requirements that specific technologies need to meet is limited. Yet, a recent study showed that stroke-related impairments and device-specific requirements are important barriers to the use of information and communication technology [12]. Additionally, a qualitative and participative study by Nasr et al. [13] of stroke survivors’ experiences with robotic technology provides insight into the values, thoughts, and feelings of potential users of a to-be-designed robotic technology for home-based rehabilitation of the hand and wrist. This study also showed that stroke survivors were more motivated to use technologies when these technologies enabled them to be independent and restored confidence in their own body [13]. Other evidence has revealed that people will employ technological devices that help them to perform their daily activities and to solve problems more easily [14]. Both studies confirm the importance of engaging with potential users to identify their requirements and subsequently to envision system requirements based on their views [13, 14].

The overall aim of the present study was to identify technological solutions that might contribute to stroke patients’ participation at home, and, in particular: (1) to gain insight into the factors contributing to the reduced participation of stroke patients in their home environment; (2) to identify technological solutions that can influence these factors and contribute to participation; and (3) to gain insight into the requirements of these technologies to facilitate their use by stroke patients. In this study a general definition of ‘technological solution’ was applied, i.e., ‘every electronically driven device or application’.[…]

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