Development and user experience of an innovative multi-mode stroke rehabilitation system for the arm and hand for patients with stroke

This seems way too complicated. Create simple mirror therapy and action observation protocols and survivors will do them. Computers and digital versions just make it more likely survivors can't use them without a therapist present and they become completely useless in third world countries.

Development and user experience of an innovative multi-mode stroke rehabilitation system for the arm and hand for patients with stroke

• Yu-Wei Hsieh,
• Meng-Ta Lee,
• Chih-Chi Chen,
• Fu-Lin Hsu &
• Ching-Yi Wu 

Scientific Reports volume 12, Article number: 1868 (2022) Cite this article

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Abstract

Many individuals with stroke experience upper-limb motor deficits, and a recent trend is to develop novel devices for enhancing their motor function. This study aimed to develop a new upper-limb rehabilitation system with the integration of two rehabilitation therapies into one system, digital mirror therapy (MT) and action observation therapy (AOT), and to test the usability of this system. In the part I study, the new system was designed to operate in multiple training modes of digital MT (i.e., unilateral and bilateral modes) and AOT (i.e., pre-recorded and self-recorded videos) with self-developed software. In the part II study, 4 certified occupational therapists and 10 stroke patients were recruited for evaluating usability. The System Usability Scale (SUS) (maximum score = 100) and a self-designed questionnaire (maximum score = 50) were used. The mean scores of the SUS were 79.38 and 80.00, and those of the self-designed questionnaire were 41.00 and 42.80, respectively, for the therapists and patients after using this system, which indicated good usability and user experiences. This novel upper-limb rehabilitation system with good usability might be further used to increase the delivery of two emerging rehabilitation therapies, digital AOT and MT, to individuals with stroke.

Introduction

Stroke is the leading cause of functional impairment and long-term disability among adults worldwide^1,2. The incidence of stroke will increase to 35% in 2050 as the proportion of older adults rises³, and the cost and burden of post-stroke care remain substantial^2,4. Four-fifths of stroke survivors experience arm and hand paresis with different degrees of severity⁵, and up to 66% of patients with affected upper limbs are still incapable of performing daily activities at 6 months post-stroke⁶. Thus, one of the top priorities in stroke rehabilitation is to develop and provide effective and specific interventions for improving upper-limb motor recovery and function in patients.

Over the last few years, mirror therapy (MT) and action observation therapy (AOT) have become promising approaches to enhance the efficacy of stroke motor rehabilitation⁷. In conventional MT, patients observe a reflection of the movements of the non-affected upper limb as if it were the affected one by using a plain mirror or mirror box^8,9. Conventional MT is a simple, easy-to-use, and relatively low cost intervention⁹. During AOT, patients carefully observe motor acts in video clips and then physically practice the observed motor acts to the best of their ability¹⁰. Previous meta-analyses found that, compared with control interventions, AOT had significant small-to-moderate effects on arm and hand motor impairment and motor function^11,12 and moderate-to-large effects on functional independence in basic activities of daily living¹¹. Similarly, MT had significant medium effects on arm and hand motor impairment and motor function^9,13,14 and small-to-moderate effects on functional independence in basic activities of daily living^9,14, respectively.

Nevertheless, the use of a mirror box or a plain mirror in conventional MT may cause imbalances in trunk control and weight shifting, and a weak sense of body ownership, and the diversity of motor movements and tasks is limited^15,16. Moreover, the pre-recorded video clips of AOT and the reflected visual illusions of MT in a mirror or mirror box may constrain the variety of therapeutic movements and functional tasks. In AOT, the pre-recorded video clips, especially those of functional tasks, may not be suitable for each individual patient’s needs; in MT, the limited space of the mirror box or the size of the mirror may restrict types of therapeutic tasks that the patients can practice.

Given the current advances in digital imaging technology, real-time video-captured images and computer-mediated visual feedback and stimuli have been developed and widely used in stroke rehabilitation^{17,18,19,20,21,22,23}. Recently, some studies have recorded movements executed mainly by the non-affected hand of patients, immediately transformed the actions of the non-affected hand, and presented them on a screen or in goggles via cameras, webcams, or virtual reality technology^{17,19,21,23,24,25}. This approach using real-time video-captured images broadens the diversity of movements and functional tasks and allows the users to record individual videos by themselves, which helps to overcome some limitations of conventional MT and AOT. These studies have also demonstrated the benefits of these devices or systems in improving upper-limb motor impairments in patients with stroke. Previous studies have found that computer-mediated visual illusions and real mirrored images produce similar degrees of neural activation^16,26. Thus, computer-mediated visual feedback and stimuli (e.g., images or videos) may strengthen the clinical utility of MT and AOT.

Nowadays, for patients with stroke, computerized or digital MT devices focusing on upper-limb training have been widely developed with different technologies, such as digital imaging systems²⁵, augmented reflection technology¹⁹, virtual-reality based equipment^23,24, and camera-based mirror visual feedback¹⁷. These devices have the following individual advantages over conventional MT: (1) They minimize the tension of the cervical posture, asymmetry of the head and trunk, and weight shifting while the reflected images are viewed on a screen or in goggles^{17,19,21,23,25}; (2) they increase the possibility of executing asymmetrical and reciprocal upper-limb movements^21,25 or broadening the range of motion exercise and simulated real-life tasks^23,24; and (3) they provide more vivid and convincing visual illusions when the reflected movements of the non-affected hand are directly superimposed on the affected hand on a computer screen^17,19. In addition, some of them demonstrate clinical feasibility in stroke rehabilitation^17,19,21,23. Although the space for performing all types of upper-limb movements or functional tasks¹⁷ may still be restricted or insufficient, computerized or digital MT devices show apparent promise.

With the evolution of digital imaging technology, it is now possible to extend and integrate the concepts of the two observational types of motor learning, conventional MT and AOT, to create a novel system/interface for wider clinical application. Integrating two effective and promising rehabilitation therapies, AOT and MT, into one digital system to achieve a more eclectic approach is needed for research and clinical use. This study aimed (1) to develop a new multi-mode stroke rehabilitation (MSR) system integrating digital AOT and MT and (2) to test the usability of this new system.