Posts Tagged usability

[ARTICLE] A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems – Full Text

Abstract

The appropriate development of tele-rehabilitation platforms requires the involvement and iterative assessments of potential users and experts in usability. Usability consists of measuring the degree to which an interactive system can be used by specified final users to achieve quantified objectives with effectiveness, efficiency, and satisfaction in a quantified context of use. Usability studies need to be complemented by an accessibility assessment. Accessibility indicates how easy it is for a person to access any content, regardless of their physical, educational, social, psychological, or cultural conditions. This chapter intends to conduct a systematic review of the literature on usability and accessibility in tele-rehabilitation platforms carried out through the PRISMA method. To do so, we searched in ACM, IEEE Xplore, Google Scholar, and Scopus databases for the most relevant papers of the last decade. The main result of the usability shows that the user experience predominates over the heuristic studies, and the usability questionnaire most used in user experience is the SUS. The main result of the accessibility reveals that the topic is only marginally studied. In addition, it is observed that Web applications do not apply the physical and cognitive accessibility standards defined by the WCAG 2.1.

1. Introduction

Innovation and technological advances involve the offering of valuable products and services to improve the quality of life of citizens. In recent decades, the domain of telemedicine has reported advances in the control, monitoring and evaluation of various clinical conditions [1]. In the field of rehabilitation, numerous studies and state-of-the-arts from informatics perspective [2] and different areas of application [34], show the effectiveness and advantages of the use of remote rehabilitation (or tele-rehabilitation) [56]. Tele-rehabilitation aims to reduce the time and costs of offering rehabilitation services. The main objective is to improve the quality of life of patients [7]. Tele-rehabilitation cannot replace traditional neurological rehabilitation [8]. It is considered as a partial replacement of face-to-face physical rehabilitation [9]. Tele-rehabilitation uses mainly two groups of technologies: (1) wearable devices and (2) vision-based systems based on depth cameras and intelligent algorithms [10]. In [5], the authors describe and analyze some characteristics and typical requirements tele-rehabilitation systems.

Design and conception of tele-rehabilitations platforms that do not consider guidelines, metrics, patterns, principles, or practice success factors can affect the access to the service, the effectiveness, quality, and usefulness. It can cause problems of confusion, error, stress, and abandonment of the rehabilitation plan. Therefore, guaranteeing the correct use of these applications implies to incorporate different studies of usability in the life cycle of the interactive system. For this reason, aspects of human factors engineering in tele-rehabilitation systems have been studied with the aim of providing accessible, efficient, usable and understandable systems [1112].

User-centered agile development (UCD) approaches allows developers to specify and design the set of interfaces of any interactive system in a flexible and effective way [1314]. The agile development life cycle centered on user experience (UX-ADLC) allows iteratively evaluating system interfaces based on the results of the previous iteration. The evaluation also includes the errors and usability problems encountered [15]. Thus, usability studies are an essential aspect of technology development [16]. This is the reason why designers need to meet usability and user experience objectives while adhering to agile principles of software development. Formative and summative usability tests are methods of evaluating software products widely adopted in user-centered design (UCD) [15] and agile UX development lifecycle. Both approaches are frequently used in the development of software applications. Rapid formative usability should be carried out so as to fulfill UX goals while satisfying end users’ needs. Formative usability is used as an iterative test-and-refine method performed in the early steps of a design process, in order to detect and fix usability problems [15]. Summative usability allows for assuring, in later phases of the design, the quality of the user experience (UX) for a software product in development. The focus is on short work periods (or iterations) where usability tests (formative and summative) must be contemplated. This means that quick formative usability tests should be carried out to fulfill UX goals [17].

The ISO 9241-11 standard [18] is a framework for understanding and applying the concept of usability to situations in which people use interactive systems and other types of systems (including built environments), products (including industrial and consumer products) and services (including technical and personal services). Likewise, the usability standard ISO 9241-11 facilitates the measurement of the use of a product with the aim of achieving specific objectives with effectiveness, efficiency and satisfaction in a context of specific use [18].

Usability can be studied through software evaluation methods widely accepted in user centered design (UCD) [15]. It can be formative or summative [8]. Formative usability consists of a set of iterative tests carried out in the early stages of the design process. The aim of the tests is to refine and improve the software product, as well as to detect and solve potential usability problems. As a complement, the summative usability allows to obtain an evaluation of the user experience (UX) for a software product in development. Formative usability facilitates decision making during the design and development of the product, while summative usability is useful when studying user experience (UX).

Tullis and Stetson [19] evaluated the effectiveness of the most used questionnaires to measure the summative usability. The authors found that the System Usability Scale (SUS) [20] and the IBM Computer System Usability Questionnaire (CSUQ) [21] are the most effective. SUS provides a quick way for measuring the usability through user experience. It consists of a 10-item questionnaire with 5-likert scale range from “Strong Agree” to “Strongly Disagree.” The CSUQ focuses on three main aspects: (1) the utility, which refers to the opinion of users regarding the ease of use, the ease of learning, the speed to perform the operations, the efficiency in completing tasks and subjective feeling; (2) the quality of the information which studies the subjectivity of the user regarding the management of system errors, the clarity of the information and the intelligibility; and finally, (3) the quality of the interface which measures the affective component of the user’s attitude in the use of the system.

Large part of the tasks in the tele-rehabilitation systems are carried out by patients who require to treat a temporary disability. Considering the special needs of these users, usability evaluations alone cannot guarantee an appropriate design of the system. On the contrary, accessibility studies can provide the mechanisms to offer the same means of use to all users of any interactive system. A study combining usability and accessibility was presented in [22]. The study analyzes how remote and/or video monitoring technologies affect the accessibility, effectiveness, quality and usefulness of the services offered by tele-rehabilitation systems. To do this, the authors provide an overview of the fundamentals necessary for the analysis of usability, in addition to analyzing the strengths and limitations of various tele-rehabilitation technologies, considering how technologies interact with the clinical needs of end users such as accessibility, effectiveness, quality and utility of the service [22].

For many people, the Web is a fundamental part of everyday life. Therefore, a fundamental aspect to ensure the inclusivity of a Website is its accessibility. For example, people who cannot use their arms to write on their computer can use a mouth pencil [23]. Or someone who cannot listen well can use subtitles to understand a video. Also, a person who has a low vision can use a screen reader to listen what is written on the screen [24]. Therefore, Web accessibility means that people with disabilities can use the Web without any type of barriers [24]. There are several standards related to accessibility that provide guidelines and recommendations [25]. Some of the most important, according to the International Organization for Standardization (ISO), are the following ones:

  • ISO 9241: covers ergonomics of human-computer interaction.

  • ISO 14915 (software ergonomics for multimedia user interfaces): multimedia controls and navigation structure.

  • ISO CD 9241-151 (software ergonomics for World Wide Web user interfaces): designs of Web user interfaces.

  • ISO TS 16071 (guidance on accessibility for human-computer interface): recommendations for the design of systems and software applications that allows a greater accessibility to computer systems for users with disabilities.

  • ISO CD 9241-20: accessibility guideline for information communication, equipment and services.

The Web Accessibility Initiative (WAI) [26] from the World Wide Web Consortium (W3C) [27] develops Web Content Accessibility Guidelines (WCAG) [28] 2.0 (at present 2.1) that covers a wide range of recommendations for making Web contents more accessible. These guidelines were considered a standard in 2012, the ISO/IEC 40500. Complementary to these guidelines are the W3C User Agent Accessibility guidelines [29] (UAAG) and Authoring tool Accessibility guidelines [30] (ATAG), which addresses the current technological capabilities to modify the presentation based on the device capabilities and the preferences of the user.

The World Wide Web Consortium (W3C) provides international standards to make the Web as accessible as possible. It comprises the Web 2.0 Content Accessibility Guidelines (WCAG 2.0) [31], also known as the ISO 40500 [32], which are adapted to the European Standard called EN 301549 [33].

The current version of the accessibility guidelines is “Web Content Accessibility Guidelines 2.1” (WCAG 2.1) [23]. WCAG 2.1 consists of 4 principles, 13 guidelines and 76 compliance criteria. The four principles refer to [34].

Principle 1—perceptibility: refers to the good practices regarding the presentation of information and user interface components. It consists of 4 guidelines and 29 compliance criteria.

Principle 2—operability: the components of the user interface and navigation must be operable. It includes 5 guidelines and 29 compliance criteria.

Principle 3—comprehensibility: the information and user interface management must be understandable. It has 3 guidelines and 17 compliance criteria.

Principle 4—robustness: the content must be robust enough to rely on the interpretation of a wide variety of user agents, including assistive technologies. It includes a guideline and three compliance criteria.

Usability and accessibility can be combined to achieve the development of more accessible, efficient, equitable and universal tele-rehabilitation systems. This chapter presents a systematic literature review of summative and formative usability studies as well as accessibility studies in the context of tele-rehabilitation systems. The remaining of the manuscript is composed of four sections. Section 2 presents the method used to proceed with the systematic review. Section 3 is a description of the most relevant papers in usability applied to tele-rehabilitation. Section 4 describes the results regarding the accessibility. And Section 5 draws conclusions on the main findings of this literature review.[…]

 

Continue —> A Systematic Review of Usability and Accessibility in Tele-Rehabilitation Systems | IntechOpen

Figure 1.
PRISMA 2009 flow diagram chart that shows the selection process of the papers included in the literature review for usability.

, , , ,

Leave a comment

[Abstract] A three-site clinical investigation and feasibility study of a flexible functional electrical stimulation system to support functional task practice for upper limb recovery in people with stroke.

Introduction: Of those people who survive a stroke, only between 40% and 70% regain upper limb dexterity. A number of reviews have suggested that functional electrical stimulation (FES) may have a beneficial effect on upper limb motor recovery. In light of the promise offered by FES and the limitations with current systems a new system was developed (FES-UPP) to support people with stroke (PwS) to practice a range of voluntary controlled, FES-assisted functional activities.

Objective: This paper reports on a three centre clinical investigation with the primary aim of demonstrating compliance of the new FES system with relevant essential requirements of the EU Medical Device Directive, namely to evaluate whether use of the FES-UPP enables PwS to perform a wider range of functional activities, and/or perform the same activities in an improved way.

Design: Clinical investigation and feasibility study

Settings: An in-patient stroke unit, a combined Early Supported Discharge (ESD) and community service, and an outpatient clinic and in-patient stroke unit.
Participants: Nine therapists and 22 PwS with an impaired upper limb.
Intervention: Every PwS was offered up to 8 sessions of FES-UPP therapy, each lasting approximately one hour, over a period of up to six weeks.
Primary and secondary outcome measures: The operation, acceptability and feasibility of the interventions were assessed using video rating and the Wolf Motor Function Test Functional Ability Scale (WMF-FAS), direct observations of sessions and questionnaires for therapists and PwS.

Results: The system enabled 24% (Rater A) and 28% (Rater B) of PwS to carry out a wider range of functional tasks and improved the way in which the tasks were performed (mean scores of 2.6 and 2.2 (with FES) versus mean scores 1.5 and 1.3 (without FES) (p<.05).

Conclusion: The FES-UP proved feasible to use in three different clinical environments, with PwS who varied widely in their impairment levels and time since stroke. Therapists and therapy assistants from a wide range of backgrounds, with varying degrees of computer and/or FES knowledge, were able to use the system without on-site technical support.

via Frontiers | A three-site clinical investigation and feasibility study of a flexible functional electrical stimulation system to support functional task practice for upper limb recovery in people with stroke. | Neurology

, , , , , , ,

Leave a comment

[Abstract + References] Patient Evaluation of an Upper-Limb Rehabilitation Robotic Device for Home Use – IEEE Conference Publication

Abstract

The paper presents a user study to compare the performance of two rehabilitation robotic systems, called HomeRehab and PupArm. The first one is a novel tele-rehabilitation system for delivering therapy to stroke patients at home and the second one has been designed and developed to provide rehabilitation therapy to patients in clinical settings. Nine patients with different neurological disorders participated in the study. The patients performed 16 movements with each robotic platform and after that they filled a usability survey. Moreover, to evaluate the patient’s performance with each robotic device, 8 movement parameters were computed from each trial and for the two robotic devices. Based on the analysis of subjective assessments of usability and the data acquired objectively by the robotic devices, we can conclude that the performance and user experience with both systems are very similar. This finding will be the base of more extensive studies to demonstrate that home-therapy with HomeRehab could be as efficient as therapy in clinical settings assisted by PupArm robot.

 

1. WHO global report. Preventing Chronic Diseases: A Vital Investment, World Health Organization, 2005.

2. J. Mackay, G. A. Mensah, The Atlas of Heart Disease and Stroke, Geneva, Switzerland:World Health Organization, 2004.

3. D. S. Nichols-Larsen, P. C. Clark, A. Zeringue, A. Greenspan, S. Blanton, “Factors Influencing Stroke Survivors Quality of Life during Subacute Recovery”, Stroke, vol. 36, pp. 14801484, 2005.

4. P. Langhorne, F. Coupar, A. Pollock, “Motor Recovery after Stroke: a Systematic Review”, The Lancet Neurology, vol. 8, no. 8, pp. 741754, 2009.

5. C. R. Carnigan, H. I. Krebs, “Telerehabilitation Robotics: Bright Lights Big Future?”, Journal of Rehabilitation Research and Development, vol. 43, no. 5, pp. 695-710, 2006.

6. K. J. Ottenbacher, P. M. Smith, S. B. Illig, R. T. Linn, G. V. Ostir, C. V. Granger, “Trends in Length of Stay Living Setting Functional Outcome and Mortality following Medical Reha-bilitation”, JAMA, vol. 292, no. 14, pp. 1687-1695, 2004.

7. L. Richards, C. Hanson, M. Wellborn, A. Sethi, “Driving Motor Recovery after Stroke”, Topics in Stroke Rehabilitation, vol. 15, no. 5, pp. 397411, 2008.

8. S. M. Linder, A. B. Rosenfeldt, A. Reiss, S. Buchanan, K. Sahu, C. R. Bay, S. L. Wolf, J. L. Alberts, “The Home Stroke Rehabilitation and Monitoring System Trial: A Randomized Controlled Trial”, International Journal of Stroke, vol. 8, no. 1, pp. 1747-4949, 2013.

9. T. Larsen, T. S. Olsen, J. Sorensen, “Early Home-Supported Discharge of Stroke Patients: A Health Technology Assessment”, International Journal of Technology Assessment in Health Care, vol. 22, no. 3, pp. 313-320, 2006.

10. Ifiaki Díaz, José María Catalan, Francisco Javier Badesa, Xabier Justo, Luis Daniel Lledo, Axier Ugartemendia, Jorge juan Gil, Jorge Díez, Nicolás García-Aracil, Development of a robotic device for post-stroke home tele-rehabilitation. Advances in Mechanical Engineering, vol. 10, no. 1, pp. 1-8, 2018.

11. J. Brooke, P. W. Jordan, B. Thomas, B. A. Weerd-meester, J. L. McClealland, “SUS: A quick and dirty usability scale” in Usability Evaluation in Industry, London:Taylor and Francis, pp. 189194, 1996.

12. R. Likert, G. M. Maranell, “A method of constructing an attitude scale” in Scaling: A Sourcebook for Behavioral Scientists, Chicago, IL:Aldine Publishing, pp. 233243, 1974.

13. H. J. Krebs, N. Hogan, M. L. Aisen, B. T. Volpe, “Robot-aided neurorehabilitation”, IEEE Transactions on Rehabilitation Engineering, vol. 6, no. 1, pp. 75-87, Mar 1998.

14. Franciso J Badesa, Ana Llinares, Ricardo Morales, Nicolas Garcia-Aracil, Jose M Sabater, Carlos Perez-Vidal, “Pneumatic planar rehabilitation robot for post-stroke patients”, Biomedical Engineering: Applications Basis and Communications, vol. 26, no. 2, pp. 1450025, 2014.

15. D. Lledo Luis, A. Diez Jorge, Bertomeu-Motos Arturo, Ezquerro Santiago, J. Badesa Francisco, M. Sabater-Navarro Jose, Garca-Aracil Nicolas, “A Comparative Analysis of 2D and 3D Tasks for Virtual Reality Therapies Based on Robotic-Assisted Neurorehabilitation for Post-stroke Patients”, Frontiers in Aging Neuroscience, vol. 8, pp. 205, 2016.

16. A. Llinares, F. J. Badesa, R. Morales, N. Garcia-Aracil, J. Sabater, E. Fernandez, “Robotic assessment of the influence of age on upper-limb sensorimotor function”, Clin. Interv. Aging, vol. 8, pp. 879, 2013.

17. D. S. Dunn, Statistics and data analysis for the behavioral sciences, New York, NY, US:McGraw-Hill, 2001.

18. J. Brooke, P. W. Jordan, B. Thomas, B. A. Weerd-meester, I. L. McClealland, “SUS: A quick and dirty usability scale” in Usability Evaluation in Industry, London:Taylor and Francis, pp. 189194, 1996.

19. AM Coderre, AA Zeid, SP Dukelow et al., “Assessment of upper-limb sensorimotor function of subacute stroke patients using visually guided reaching”, Neurorehabil Neural Repair., vol. 24, no. 6, pp. 528541, 2010.

via Patient Evaluation of an Upper-Limb Rehabilitation Robotic Device for Home Use – IEEE Conference Publication

, , , , , , , , , , ,

Leave a comment

[ARTICLE] Characteristics, Usability, and Users Experience of a System Combining Cognitive and Physical Therapy in a Virtual Environment: Positive Bike – Full Text HTML

Abstract

We present the architecture and usability evaluation of virtual reality system—“Positive Bike”—designed for improving cognitive and motor conditions in frail elderly patients. The system consists of a cycle-ergometer integrated in an immersive virtual reality system (CAVE) which allows combining motor and cognitive exercises according to a “dual-task” paradigm. We tested the usability and user’s experience of the prototype in a pilot evaluation study that involved five elderly patients. The prototype was tested in one-session training to understand the limitations and areas for improvement of our system. The evaluation consisted in (i) usability assessment using the system usability scale; (ii) evaluation of user’s engagement using the flow state scale; and (iii) expert evaluation involving interviews with domain experts. Results showed a good usability, both for system usability scale and the semi-structured interview. The level of flow (i.e., enjoyment with the task at hand) measured using the short flow state scale, was also high. Analysis of semi-structured interview carried out with domain experts provided further indications to improve the system. Overall, these findings show that, despite some limitations, the system is usable and provides an enjoyable user’s experience.

1. Introduction

1.1. The Problem of Frailty

Aging is a physiological process involving both cognitive and motor domains, and affecting many aspects of everyday life. According to the World Health Organization, the proportion of people older than 60-year-old is increasing rapidly and faster than all the other age groups [1]. In the population, in the last decade, there has been a lot of interest in “frail” patients, constituting the 6.9% of adults older than 65-year-old [2]. Specifically, frailty is a clinical condition and a state of vulnerability associated with increasing age and affecting multiple domains such as gait, mobility, balance and cognition [3]. According to the standardized definition of Fried and colleagues, three or more of the following criteria should be met: unintentional weight loss (10 lbs in past year), self-reported exhaustion, weakness (grip strength), slow walking speed, and low physical activity [2]. Evidence of a strong association between this condition and higher risks for adverse health outcomes, such as mortality, disability and, especially, high risk of falls, has been shown [2,4,5,6].
Even though cognitive and motor impairments have been considered and treated independently, literature is showing evidence for a strong relation between them, both in healthy and pathological conditions. An example of this relationship is the risk of falls. Among old adults and frail patients, falls are one of the most critical public health problems, as well as the major cause of injuries: one in three old people, indeed, falls at least once in a year [7], with subsequent consequences in terms of loss of independence and adverse psychosocial problems [8,9]. The increased fall rate among older adults has been interpreted in light of the cognitive-motor interference (CMI) theory [10,11].
CMI, a specific type of dual task interference (DTi), refers to the simultaneous execution of a cognitive and a motor task, that requires a great amount of cognitive control in terms of executive functions and attentional abilities [12]. The concurrent performance of a cognitive task can cause a decline either in the motor or in the cognitive execution, or even in both, depending on the cognitive demand [1,12,13]. Current literature has shown that the mechanisms supporting DT are still unclear. As a matter of fact, a specific brain structure devoted to the control of DT has not been yet identified: rather than being a simple addictive effect, DT could be the result of a complex coordination and interplay between different specialized information-processing systems [14]. Concerning the cognitive mechanisms, instead, two different attentional theories have been proposed. Along with the Wickens’ theory of shared attentional resources [15], the concurrent execution of two activities would require to divide and re-allocate attention, thus decreasing the attentional resources assigned to each single task [16]. On the other hand, the bottleneck hypothesis argues that the main cause of interference would be the competition for information-processing in neural pathways [16]: tasks that are supported by a similar neural network could not be carried out in parallel, but only in sequence.
Interestingly, successful locomotion requires the ability of performing simultaneously a cognitive task that can cause an interference in gait performance, especially in older adults. Several works showed the efficacy of this paradigm [17,18,19,20]. The age-related decrease in attentional and executive functioning would impair the ability of managing the concurrent execution of different motor and cognitive activities, normally occurring in everyday life [21,22]. Notably, frailty has been described as a reversible dynamic process, characterized by recurrent transitions between states over time [23]. As a consequence, a growing number of studies focuses on the possibility of creating specific interventions, either to improve or prevent frailty and, specifically, to reduce the risk of fall [24]. For instance, regular physical exercise and motor interventions, either in their aerobic or strength form [25], were proved to bring many benefits for reducing the fall risk [26,27,28,29] and improving general cognitive functioning [30]. Accordingly, a recent systematic review showed the main role played by muscular strength and postural balance for the prevention of falls [28].
Recently, DT has been suggested as a more efficient approach for the improvement of cognitive and motor performances [21,31,32,33]. Specifically, the important contribution of high-order cognitive systems in gait control would make DT an effective training for the reduction of fall risk [21].

1.2. The Potential of Virtual Reality to Counteract Frailty

Thanks to the development of new technologies and to the great diffusion of virtual reality (VR) in the clinical field, it is now possible to develop and implement interactive cognitive-motor training. VR offers indeed the opportunity to create ecological and realistic environments in which to reproduce daily-life situations, leading to higher acceptance and adherence rates among patients [34]. In addition, VR allows rehabilitation practice to become more engaging, thus increasing users’ motivation and performances; finally, VR—coupled with appropriate sensors—enables measuring different objective behaviors in real-time, thus allowing the provision of training in a valid, safe, and controlled environment.
The adoption of VR training, mainly involving balance and functional mobility, has already shown promising outcomes in the clinical field, thus suggesting VR as an appropriate complementary approach in the field of rehabilitation [35]. With respect to elderly rehabilitation programs, and the implementation of fall prevention exercise, many VR-based studies can be traced in literature [36]; among them, the use of balance boards and the implementation of a balance training program using commercial games from the Wii Fit software package (i.e., yoga, soccer, ski jump, tennis) are quite common [37,38,39]. In the majority of the cases, VR-based balance programs resulted in improved postural balance and fear of falling in the experimental groups when compared to no treatment [36]. Other setups foresee the exploitation of step pads and/or of the Kinect sensor, and the provision of visual feedback on a TV screen to support the maintenance of the adequate step rhythm [40] or the awareness of quality of the performance [41]. A recent study investigated the effects of the addition of a non-immersive virtual reality component to treadmill training aimed at reducing fall risk in older adults [42]; in this case, VR was used to increase the ecological validity of the training, providing older adults with real-life challenges such as obstacles and distractors requiring continual adjustment of steps. The whole system included the treadmill, a safety harness, a virtual environment displayed on a TV screen, and a Kinect sensor tracking the participants’ steps. Six months after the end of the program, the group who underwent the training using treadmill reported a significant decrease in fall incident rate, with respect to the group who trained with treadmill alone.
Several studies already adopted a VR cycling training for the motor rehabilitation of old adults or stroke patients [43,44,45,46,47], but no one ever implemented it into a DT protocol, thus requiring the execution of some interactive cognitive tasks during the physical performance of the virtual ride. To our knowledge, studies exploiting VR-based dual task training focused on exercises requiring locomotion and involved either the use of a treadmill [48,49] or implemented stepping-in-place on a balance board [19]. In the following, we describe the rationale, the design and the usability testing of ‘Positive Bike’, a fully-immersive VR biking experience for the implementation of an interactive DT training. Stationary cycle exercises can improve balance, weight shifts and gait, as well as lower body extremity functioning, thus translating into a significant reduction of the fall risk [46,50,51]. The pattern of cycling is indeed very close to walking, as they are both cyclical, they both involve the reciprocal flexing and extension movements from the hip, knee, and ankle, and they both activate alternatively agonist and antagonist muscles [52,53,54]. Moreover, the use of a stationary bike results in providing the user with a controllable workload and a safer equipment; indeed, with respect to the treadmill (the other equipment allowing an easy modification of the workload), the employment of a cycle-ergometer is associated with a lower risk of injury, especially in case of elderly and frail users [55].
Another key requirement was to create a task that provided participants with positive and engaging experience. According to Riva and colleagues [56,57] a key asset of VR for rehabilitation is that this technology allows creating artificial environments that promote optimal experience through surprising psychological resources and increase in the involvement. Accordingly, VR is a powerful tool that can be used to improve the engagement of the participants, thanks to the creation of challenging tasks designed accordingly to the user’s personal skills and resources. This approach, also called “transformation of flow” has shown promising results in the field of rehabilitation, both cognitive and physical [58,59].[…]

Continue —> Sensors | Free Full-Text | Characteristics, Usability, and Users Experience of a System Combining Cognitive and Physical Therapy in a Virtual Environment: Positive Bike | HTML

Sensors 18 02343 g001

Figure 1. A picture of a real set up and a schematic representation of the hardware setup.

, , , , , ,

Leave a comment

[ARTICLE] An Evaluation of the Design and Usability of a Novel Robotic Bilateral Arm Rehabilitation Device for Patients with Stroke – Full Text

Introduction: Robot-assisted therapy for upper limb rehabilitation is an emerging research topic and its design process must integrate engineering, neurological pathophysiology, and clinical needs.

Purpose of the study: This study developed/evaluated the usefulness of a novel rehabilitation device, the MirrorPath, designed for the upper limb rehabilitation of patients with hemiplegic stroke.

Methods: The process follows Tseng’s methodology for innovative product design and development, namely two stages, device development and usability assessment. During the development process, the design was guided by patients’ rehabilitation needs as defined by patients and their therapists. The design applied synchronic movement of the bilateral upper limbs, an approach that is compatible with the bilateral movement therapy and proprioceptive neuromuscular facilitation theories. MirrorPath consists of a robotic device that guides upper limb movement linked to a control module containing software controlling the robotic movement.

Results: Five healthy subjects were recruited in the pretest, and 4 patients, 4 caregivers, and 4 therapists were recruited in the formal test for usability. All recruited subjects were allocated to the test group, completed the evaluation, and their data were all analyzed. The total system usability scale score obtained from the patients, caregivers, and therapists was 71.8 ± 11.9, indicating a high level of usability and product acceptance.

Discussion and conclusion: Following a standard development process, we could yield a design that meets clinical needs. This low-cost device provides a feasible platform for carrying out robot-assisted bilateral movement therapy of patients with hemiplegic stroke.

Clinical Trial Registration: identifier NCT02698605.

Introduction

The World Health Organization (WHO) has reported that stroke is the third leading cause of death in developed countries and involves approximately 15 million stoke events annually. One-third of stroke patients die and a further one-third of events results in permanent disability. Depending on the location of the brain insult, stroke can lead to a wide range of functional impairments (Mackay et al., 2004); these include language, cognition, sensation, and motor functions. Motor impairment impacts the patient’s ability to perform activities of daily living. For the majority of patients, recovery of motor function involving an upper limb is slower than that of lower limb (Feys et al., 1998). Indeed, most activities of daily living rely the functioning of the upper limb, thus emphasizing the need for effective upper limb rehabilitation.

With an attempt to enhance the effectiveness of upper limb rehabilitation among stroke patients, a series of rehabilitation techniques have been developed and refined in recent decades; these include task-oriented motor training, constraint-induced movement therapy, mirror therapy, and bilateral movement training. Each of these methods has a number of theoretical advocates and each has been shown to be effective clinically. For instance, bilateral movement therapy, which involves coordinated movement of the bilateral upper limbs, has been shown to enhance upper limb recovery and coordination between the hands. Stoykov et al. (2009) found that bilateral arm training is more effective than unilateral training when restoring proximal upper limb function because it seems to improve the functional linkages between the bilateral hemispheres.

Even after receiving a full course of conventional rehabilitation, 60% of stroke patients still have difficulties when using their affected upper limb (Kwakkel et al., 1999). As a result, it has become the upmost importance to develop novel rehabilitation strategies that are able to help patients reach a higher level of recovery. One such approach is robot-assisted rehabilitation, which incorporates robotic technologies into the rehabilitation processes. Several well-known robot-assisted movement therapies for the upper limb has been implemented clinically, including MIT-Manus (Krebs et al., 1998), Bi-Manu-Track (Hesse et al., 2003), BATRAC (Cauraugh et al., 2010), and MIME (Burgar et al., 2000), each of which follows different movement therapy theories. Regarding the body parts that are mainly involved in therapy, Bi-Manu-Track focuses on the bilateral forearms and wrists, while BATRAC and MIME focus on the shoulder and elbow of the affected limb. Regarding the movement dimension, BATRAC involves movement in one-dimension, while MIME allows three-dimensional movement. In fact, the higher the degrees of freedom adopted during the movement therapy, the more complex is the design of the robotic device. As a result, it has become important to come up with a feasible design that fulfills the patient’s rehabilitation needs while avoiding the high costs that can be associated with instrument acquirement and maintenance. Furthermore, the effectiveness of the system needs to be comparable to that provided by conventional therapies so that a motivation to pursue this therapeutic option can be established (Kwakkel et al., 2008; Lo et al., 2010).

As an approach to the development of mechanical rehabilitation devices for hemiplegic upper limbs, Timmermans et al. (2009) proposed that three design domains are required; these were the therapy techniques used, the motivation of the patient, and resulting performance rewards. An online survey of physical therapists, 233 in total, indicated that a preferred upper limb robotic device needs to accommodate different hand movements, to be able to be used while in a seated position, to be able to provide the user with feedback, to focus on the restoration of activities of daily living, to able to be used at home, to have adjustable resistance levels and to cost less than US$6,000 (Lu et al., 2011).

In terms of usability, the interaction between the user and the machine tends to be overlooked during the development stage. Although a variety of upper limb rehabilitation machines have been proposed, only a few have been commercialized. This low market acceptance can be attributed to the high cost of these devices, safety concerns, and poor usability (Lee et al., 2005). To this end, the aim of this study was to design a bilateral upper limb rehabilitation device called MirrorPath for the rehabilitation of stroke patients that follows the theories of bilateral movement therapy and proprioceptive neuromuscular facilitation (PNF). These two theories were initially developed by Knott and Kabat and have been shown to have a positive effect on the range of active and passive motions needed by stroke patients (Sharman et al., 2006). Our device will guide the patient’s upper limbs, each of which moves along a diagonal motion path on the horizontal plane. The position and velocity of motion of the bilateral limbs are perfectly mirrored across the midline on the table. Finally, usability testing was conducted on the completed prototype.

Continue —>  Frontiers | An Evaluation of the Design and Usability of a Novel Robotic Bilateral Arm Rehabilitation Device for Patients with Stroke | Frontiers in Neurorobotics

Figure 2. (A) A patient performed bilateral diagonal movements using the device; (B) due to weakness of right upper limb, the patient’s grip was assisted with an elastic bandage, and the patient’s elbow was support by a sling; (C) the application scenario.

, , , , , , , , ,

Leave a comment

[ARTICLE] USEQ: A Short Questionnaire for Satisfaction Evaluation of Virtual Rehabilitation Systems – Full Text HTML

Abstract

New emerging technologies have proven their efficacy in aiding people in their rehabilitation. The tests that are usually used to evaluate usability (in general) or user satisfaction (in particular) of this technology are not specifically focused on virtual rehabilitation and patients. The objective of this contribution is to present and evaluate the USEQ (User Satisfaction Evaluation Questionnaire). The USEQ is a questionnaire that is designed to properly evaluate the satisfaction of the user (which constitutes part of usability) in virtual rehabilitation systems. Forty patients with balance disorders completed the USEQ after their first session with ABAR (Active Balance Rehabilitation), which is a virtual rehabilitation system that is designed for the rehabilitation of balance disorders. Internal consistency analysis and exploratory factor analysis were carried out to identify the factor structure of the USEQ. The six items of USEQ were significantly associated with each other, and the Cronbach alpha coefficient for the questionnaire was 0.716. In an analysis of the principal components, a one-factor solution was considered to be appropriate. The findings of the study suggest that the USEQ is a reliable questionnaire with adequate internal consistency. With regard to patient perception, the patients found the USEQ to be an easy-to-understand questionnaire with a convenient number of questions.

1. Introduction

1.1. Usability

Usability is an important quality attribute of a user’s experience when interacting with a system or tool, and it is also an important attribute in helping users to achieve the suggested goals [1]. With regard to HCI (Human–Computer Interface) and usability, Bevan states in [2] that standards related to usability can be categorized as being primarily concerned with the use of the product (effectiveness, efficiency, and satisfaction in a specific context of use).
The categorization of Bevan is coherent with the ISO 9241-11 standard [3,4,5], which describes a widely accepted definition of usability. This standard indicates the rules that are needed in terms of ergonomics, hardware, software, and environments in order to obtain good usability for a product or system. Section 8.1 describes the term usability as “the extent to which a product can be used by specified users to achieve specified goals with effectiveness, efficiency and satisfaction in a specified context of use”.

1.2. Usability in Virtual Rehabilitation

One of the promising and emerging fields within rehabilitation therapies for different pathologies is virtual rehabilitation (VRh) [6,7,8,9]. VRh systems are designed to assist clinical specialists and patients in the rehabilitation process [10]. The use of ground-breaking technologies together with the emergence of entertaining and playful virtual environments (VE) have demonstrated promising results in the rehabilitation process [11,12,13,14], improving the adherence to treatments [12]. However, these systems should be tested regarding important aspects such as usability.
Currently, there are different questionnaires that are designed to evaluate usability in general-purpose systems. The best-known usability questionnaire is the system usability scale (SUS) [15,16], which measures the feeling of usability of the users when using computer systems. It is composed of 10 questions with a five-point Likert attitude scale (from strongly disagree to strongly agree). This questionnaire has been used in different domains such as: security software [17], mobile phones [18,19], PDA [20], Social Network sites [21,22], wiki sites [23], serious games [24], or robotics [25]. Even though the SUS questionnaire is not specifically designed for VRh systems, it has also been used for rehabilitation purposes due to the lack of questionnaires that focus on VRh systems. Meldrum et al. [26] tested balance in patients with vestibular and other neurological diseases using VRh and quantified the usability of the Nintendo Wii Fit Plus®. Duvinage et al. [27] assessed the usability of a P300 system (using Brain–Computer interfaces) for lower-limb rehabilitation purposes. One considerable advantage of the SUS questionnaire is the reasonable number of questions that are to be answered at the end of the first session. However, the concepts of this questionnaire are too generic (computers, PDAs, Websites, etc.). The main drawback of the SUS questionnaire is that it does not include questions to obtain responses about specific items related to Virtual Rehabilitation.
Another well-known usability questionnaire is VRUSE [28]. Fitzgerald et al. [29] assessed the usability of the E-Yoga system using VRUSE, with the goal of improving postural control and biomechanical alignment of the subjects in a rehabilitation process. The VRUSE evaluates a wide range of concepts: functionality, user input, system output (display), user guidance and help, consistency, flexibility, simulation fidelity, error correction/handling and robustness, sense of immersion/presence, and overall system usability. The main drawback of this test is the large number of questions that the patients are required to answer [28]: the complete questionnaire has 100 questions. This drawback is especially important if the patients involved in a rehabilitation process have neurological and/or cognitive disorders. Other simplified usability questionnaires for VRh with reasonable outcomes are described in [30,31,32,33], but the drawback of these questionnaires is that the internal consistency has not yet been validated.
Kizony et al. [34] published the Short Feedback Questionnaire (SFQ), which is a questionnaire that is related to Witmer and Singer’s Presence Questionnaire [35]. It is composed of eight questions with a five-point Likert attitude scale, and it has been used in virtual reality environments [36,37,38]. The SFQ questionnaire evaluates the user’s sense of presence, perceived difficulty of the task, and any discomfort that users may have felt during the experience. This questionnaire does not focus on VRh systems.
To our knowledge, there are no validated questionnaires for testing usability or satisfaction of virtual rehabilitation systems. A questionnaire for this purpose must have a reasonable number of questions and internal consistency reliability.
Following the definitions of usability in [2,3,4,5], usability can be divided into three components: efficiency, effectiveness, and satisfaction. Focusing on VRh, efficiency and effectiveness can usually be measured through a clinical trial. With a classical clinical trial, we can compare an experimental group (using a VRh system) with a control group (following a traditional rehabilitation program) by evaluating efficacy and comparing the recovery level of the two groups. With regard to effectiveness, we can measure, for instance, the number of sessions that each group needs to reach a certain level. However, the third component of usability, satisfaction, cannot be evaluated in the same way as efficiency and effectiveness: a reliable and consistent questionnaire (with an adequate number of questions) is necessary to measure the satisfaction of the users.
The aim of the present study is to introduce the USEQ, a user satisfaction questionnaire that is specifically designed to evaluate satisfaction with virtual rehabilitation systems, and to validate their reliability by analyzing their internal consistency.

2. USEQ: The User Satisfaction Evaluation Questionnaire

2.1. SEQ: The Suitability Evaluation Questionnaire

In [39], the SEQ was introduced as a 14-question questionnaire that is designed to test items such as satisfaction, acceptance, and security of use in virtual rehabilitation systems. The SEQ was designed by a multidisciplinary team of clinical and technical experts. Factors such as the length of the questionnaire, the type of questions to be asked and what to ask were taken into account in the design of the questionnaire. For the length of the questionnaire, the clinical experts that collaborated in the design of the SEQ estimated that a maximum of 15 questions would be an acceptable length for patients.
For the type of questions, the designers of the SEQ considered 13 questions with a five-point Likert Scale, plus an open-ended question offering patients the possibility to add comments if necessary. The SEQ has a five-point Likert Scale questions (instead of other options such as seven-point Likert Scale questions) because the authors considered five options of answers to be good enough, and, also, it is coherent with the main usability questionnaires that are currently being used: SUS [15], VRUSE [28], and SFQ [34] also use five-point Likert Scale questions.
For what to ask about, the designers of the SEQ composed the questions taking into account the usability questionnaires available and their own experience, both in the technical and in the clinical field.
A previous study evaluating the suitability of virtual rehabilitation for the elderly was carried out using the SEQ [40]. The SEQ was used to evaluate the ABAR (Active Balance Rehabilitation) system, the VRh system that is used in this study. The study presented in [40] allowed the evaluation of the perceived length and difficulty of the SEQ. In [40], the patients completed the questionnaire without any problems. None of the patients considered the questionnaire to be too long. The main drawback of SEQ is that it is composed of different dimensions; therefore, it is not possible to evaluate their internal consistency.

Source: Sensors | Free Full-Text | USEQ: A Short Questionnaire for Satisfaction Evaluation of Virtual Rehabilitation Systems | HTML

Figure 1. Patient interacting with the ABAR system.

 

, , , , , , , , ,

Leave a comment

%d bloggers like this: