Haptic Nudging Using a Wearable Device to Promote Upper Limb Activity during Stroke Rehabilitation: Exploring Diurnal Variation, Repetition, and Duration of Effect

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Haptic Nudging Using a Wearable Device to Promote Upper Limb Activity during Stroke Rehabilitation: Exploring Diurnal Variation, Repetition, and Duration of Effect 

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¹

Health and Rehabilitation Research Institute, Auckland University of Technology, Private Bag 92006, Auckland 1142, New Zealand

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Centre for Chiropractic Research, New Zealand College of Chiropractic, Auckland 1060, New Zealand

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Department of Statistics, University of Auckland, 38 Princes Street, Auckland 1010, New Zealand

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Callaghan Innovation, 5 Sheffield Crescent, Burnside, Christchurch 8053, New Zealand

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Author to whom correspondence should be addressed.

Behav. Sci. 2023, 13(12), 995; https://doi.org/10.3390/bs13120995

Received: 12 October 2023 / Revised: 15 November 2023 / Accepted: 27 November 2023 / Published: 2 December 2023

(This article belongs to the Section Experimental and Clinical Neurosciences)

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Abstract

Haptic nudging via wearable devices promotes physical activity and may increase upper limb movement in stroke rehabilitation. This study investigated the optimal approach to haptic nudging by examining diurnal variation, duration of effect, and repeated nudging. The study analysed data from a multiple-period randomised crossover study. A 12 h inpatient rehabilitation day was divided into 72 intervals in which participants with stroke (n = 20) randomly received either a ‘nudge’ or ‘no nudge’. Upper limb movement was observed, classified, and analysed using longitudinal mixed models. The odds of affected upper limb movement following a nudge compared with no nudge were significantly higher during active periods such as breakfast, lunch, and morning and afternoon activities (odds ratios (ORs) 2.01–4.63, 95% CIs [1.27–2.67, 3.17–8.01]), but not dinner (OR 1.36, 95% CI [0.86, 2.16]). The effect of nudging was no longer statistically significant at 50–60 s post-nudge. Consecutive delays in nudging significantly decreased the odds of moving when a nudge was eventually delivered. Contrary to expectations, people with stroke appear more responsive to haptic nudging during active periods rather than periods of inactivity. By understanding the optimal timing and frequency of haptic nudging, the design of wearable devices can be optimised to maximise their therapeutic benefits.

Keywords:

haptic nudging; wearable; stroke; upper limb; behaviour change; health technology; rehabilitation technology

1. Introduction

The field of wearable technology has seen rapid development in recent years, particularly with respect to its application in promoting physical activity. Wearables are devices that integrate built-in sensors into accessories or clothing [1], such as wristbands [2], shoes [3], and sleeves [4], to monitor users’ movement and position. Sensor data are analysed to provide feedback about physical activity either through the device or via a mobile app on a smartphone or tablet [5]. When carried by the user, smartphones themselves can also act as wearable devices utilising their inbuilt sensors [6].

For those who are proactive about their health, the use of wearables to increase physical activity has become increasingly popular [7], with low- to moderate-quality evidence supporting their efficacy in healthy adults [5]. However, their potential to promote physical activity among those with clinical and age-related conditions is an area that warrants further investigation. Wearables offer a promising avenue for monitoring and promoting physical activity both within and beyond healthcare settings [8].

As a leading cause of disability worldwide [9], stroke is a clinical condition that could benefit from wearable devices. Following stroke, rehabilitation incorporating high doses of task-specific physical activity is recommended [10,11], yet people with stroke often receive limited rehabilitation and have very low levels of physical activity [12,13]. While wearables have been used to encourage physical activity after stroke, and their potential to increase locomotor and upper limb activity is recognised by both physical therapists and people with stroke [14], the evidence for their efficacy is limited. A 2018 Cochrane review reported that wearables demonstrated no clear effect on locomotor activity after stroke [15]. However, one randomised controlled trial in people with stroke demonstrated that wearable step count monitoring increased physical activity when combined with additional behavioural change strategies such as an exercise calendar, goal setting, and praise for achievement [16].

The combination of physical activity monitoring via wearables with strategies that support behaviour change has been emphasised as an approach that may improve their efficacy [5,17,18]. Such strategies might include feedback about progress and goal attainment, rewards, coaching, social support, and nudging [18,19]. Nudging refers to the concept of manipulating choice architecture to influence decision making and behaviour [20]. Nudging has been shown to be effective at promoting physical activity in both healthy people and those with health conditions [21,22,23]. One nudging approach commonly used within wearable technologies to prompt physical activity is haptic stimulation. Haptic nudging is delivered using a small vibratory motor inside a wearable technology. Users are encouraged to respond to haptic nudging by performing a specific behaviour, for instance, completing rehabilitation exercises or resuming physical activity [24].

Within stroke rehabilitation, where clinicians seek to promote active movement in the affected upper limb [12,25], observational and feasibility studies have explored the use of haptic nudging to prompt the use of the affected upper limb [26,27]. These studies have shown that haptic nudging is not only feasible in people with stroke [26] but can also significantly increase the likelihood the user will move their affected upper limb following haptic nudging [27]. Prior to conducting larger clinical trials to establish the efficacy of wearable devices combined with behavioural change strategies to enhance upper limb recovery, the optimal method of delivering haptic nudging to promote physical activity in people with stroke should be explored. The following study utilised the BuzzNudge wearable device, which is a wrist-worn haptic nudge system that prompts users with stroke to move their affected upper limbs. Using data from a single-day inpatient stroke rehabilitation trial in which participants wore the BuzzNudge, this study explored the following research questions: (i) Is there diurnal variation in the effect of a haptic nudge? (ii) How long does the effect of a haptic nudge last? (iii) Is the effect of a haptic nudge dependent on the repetition of nudges?