Can't tell from here if a difficult case of wrist spasticity was in the group.
A usability study on mobile EMG-guided wrist extension training in subacute stroke patients-MyoGuide
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 39 (2024)
Abstract
Background
Effective stroke rehabilitation requires high-dose, repetitive-task training, especially during the early recovery phase. However, the usability of upper-limb rehabilitation technology in acute and subacute stroke survivors remains relatively unexplored. In this study, we introduce subacute stroke survivors to MyoGuide, a mobile training platform that employs surface electromyography (sEMG)-guided neurofeedback training that specifically targets wrist extension. Notably, the study emphasizes evaluating the platform’s usability within clinical contexts.
Methods
Seven subacute post-stroke patients (1 female, mean age 53.7 years, mean time post-stroke 58.9 days, mean duration per training session 48.9 min) and three therapists (one for eligibility screening, two for conducting training) participated in the study. Participants underwent ten days of supervised one-on-one wrist extension training with MyoGuide, which encompassed calibration, stability assessment, and dynamic tasks. All training records including the Level of Difficulty (LoD) and Stability Assessment Scores were recorded within the application. Usability was assessed through the System Usability Scale (SUS) and participants’ willingness to continue home-based training was gauged through a self-developed survey post-training. Therapists also documented the daily performance of participants and the extent of support required.
Results
The usability analysis yielded positive results, with a median SUS score of 82.5. Compared to the first session, participants significantly improved their performance at the final session as indicated by both the Stability Assessment Scores (p = 0.010, mean = 229.43, CI = [25.74–433.11]) and the LoD (p < 0.001; mean: 45.43, CI: [25.56–65.29]). The rate of progression differed based on the initial impairment levels of the patient. After training, participants expressed a keen interest in continuing home-based training. However, they also acknowledged challenges related to independently using the Myo armband and software.
Conclusions
This study introduces the MyoGuide training platform and demonstrates its usability in a clinical setting for stroke rehabilitation, with the assistance of a therapist. The findings support the potential of MyoGuide for wrist extension training in patients across a wide range of impairment levels. However, certain usability challenges, such as donning/doffing the armband and navigating the application, need to be addressed to enable independent MyoGuide training requiring only minimal supervision by a therapist.
Background
Stroke is the third leading cause of disability worldwide [1]. At least 50% of stroke survivors suffer from upper limb impairments that limit engagement in activities of daily living (ADLs) and reduce quality of life [2, 3]. There is a consensus that effective post-stroke upper limb rehabilitation benefits from high-dose repetitive-task training [4, 5]. Nonetheless, ensuring the delivery of sufficient training doses remains challenging, especially during the acute to subacute phases [6,7,8,9,10]. Additionally, it’s essential to emphasize the significant impact of treatment timing on post-stroke motor recovery. Research has shown that the optimal rehabilitation period occurs within the first 60 to 90 days following a stroke [11]. Furthermore, clinical trials on human subjects have consistently revealed that individuals receiving early intervention exhibit significantly better motor recovery outcomes compared to those who received delayed intervention [12,13,14]. Building on this understanding, recent studies [15, 16] also highlighted the potential of rehabilitation technologies in alleviating the burden of intensive and repetitive upper limb exercises for therapists. These technologies, facilitating high-dose upper limb rehabilitation during the early stages of stroke, even when the upper limb is still significantly weakened and unable to generate overt movement, may serve as a beneficial supplement to conventional treatment methods.
To address the unique challenges posed by post-stroke rehabilitation, various sensor-based technological solutions have been explored, such as the Leap Motion [17], Kinect [18, 19], and Myo armband [18, 20, 21]. While demonstrating promise in gesture recognition [22] and hand therapy with serious games [23, 24], the Leap Motion generally demands precise hand positioning and controlled lighting conditions [23, 25]. It is important to emphasize that the former may present practical challenges, particularly for individuals with highly impaired upper limbs, as they might encounter difficulty holding their shoulder and elbow in the necessary position for an extended duration. Kinect-based programs have also shown promise in upper limb rehabilitation [26,27,28]. However, they also exhibit technical limitations, including the complexity of use and dependence on the therapist’s assistance [19], along with challenges associated with occlusion [29], and reduced reliability for small movement amplitudes [29].
In this context, surface electromyography (sEMG) emerges as a versatile and promising avenue for post-stroke rehabilitation, alleviating users from strict positioning constraints and lighting considerations. Specifically, the integration of sEMG with the Myo armband introduces a wireless and highly portable dimension to upper limb rehabilitation. Furthermore, sEMG possesses the unique ability to detect movement intention in cases of upper limb paresis [30, 31]. Such capability is vital for stroke patients with limited active movement. The effectiveness of sEMG biofeedback has been demonstrated in prior studies, encompassing gait training [32, 33] and upper limb exercises, with notable advantages such as mitigating co-contraction patterns [34], achieving enhanced functional recovery outcomes compared to conventional therapy [35, 36], and receiving positive usability feedback from end-users [37]. The potential use of the Myo armband with gamified applications for upper limb rehabilitation is highlighted by recent studies in multiple sclerosis and stroke patients for hand/wrist rehabilitation [21, 38]. Furthermore, it’s worth noting that although the Myo armband is no longer on the market, alternatives continue to be available.
The usability of the Myo armband coupled with serious games has also been tested on both healthy participants [20] and health professionals [38]. However, its utility as a user-friendly tool in clinical settings for both stroke patients and healthcare professionals has not been thoroughly investigated. Furthermore, given the heterogeneity in the design of serious games, the generalizability of usability across different game types may be limited. To effectively pinpoint and address usability challenges, a rigorous and iterative evaluation process is required [39,40,41]. Previous studies have shown that inclusive participation of both patients and therapists has played a pivotal role in shaping the development of wearable exoskeletons [42, 43] and interactive game-based virtual reality systems [44].
Acknowledging this gap, our present research seeks to offer insights into the usability of the Myo armband integrated with a training platform specifically designed for post-stroke rehabilitation. In this study, we introduce ‘MyoGuide,’ a mobile platform with a serious game harnessing the benefits of sEMG-guided biofeedback training. Additionally, it incorporates a calibration feature to address the diverse nature of impairments observed among stroke patients. Our focus is on wrist extension training, a pivotal aspect for both activities of daily living (ADLs) [45, 46] and hand grasping actions [47, 48]. Additionally, wrist extension ability has been highlighted as a potential indicator of upper limb functional recovery [49].
In this study, our primary objective was to integrate usability assessments into the initial stages of MyoGuide’s development, targeting both stroke survivors and therapists. From stroke survivors, we aimed to gain insights into the overall usability of the training platform. From therapists, our goal was to assess whether MyoGuide serves as a tool that can be used in clinical settings. The overarching aim is to validate MyoGuide’s suitability for integration into clinical settings, particularly addressing challenges related to intensive and repetitive upper limb exercises.
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