This obviously was tried on high functioning individuals. Nobody like me with spasticity that prevents voluntary movement. So going against the precept of 'Leave no survivor behind!'
Utility and usability of a wearable system and progressive-challenge cued exercise program for encouraging use of the more involved arm at-home after stroke—a feasibility study with case reports
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 66 (2024)
Abstract
Background
Understanding the role of adherence to home exercise programs for survivors of stroke is critical to ensure patients perform prescribed exercises and maximize effectiveness of recovery.
Methods
Survivors of hemiparetic stroke with impaired motor function were recruited into a 7-day study designed to test the utility and usability of a low-cost wearable system and progressive-challenge cued exercise program for encouraging graded-challenge exercise at-home. The wearable system comprised two wrist-worn MetaMotionR+ activity monitors and a custom smartphone app. The progressive-challenge cued exercise program included high-intensity activities (one repetition every 30 s) dosed at 1.5 h per day, embedded within 8 h of passive activity monitoring per day. Utility was assessed using measures of system uptime and cue response rate. Usability and user experience were assessed using well-validated quantitative surveys of system usability and user experience. Self-efficacy was assessed at the end of each day on a visual analog scale that ranged from 0 to 100.
Results
The system and exercise program had objective utility: system uptime was 92 ± 6.9% of intended hours and the rate of successful cue delivery was 99 ± 2.7%. The system and program also were effective in motivating cued exercise: activity was detected within 5-s of the cue 98 ± 3.1% of the time. As shown via two case studies, accelerometry data can accurately reflect graded-challenge exercise instructions and reveal differentiable activity levels across exercise stages. User experience surveys indicated positive overall usability in the home settings, strong levels of personal motivation to use the system, and high degrees of satisfaction with the devices and provided training. Self-efficacy assessments indicated a strong perception of proficiency across participants (95 ± 5.0).
Conclusions
This study demonstrates that a low-cost wearable system providing frequent haptic cues to encourage graded-challenge exercise after stroke can have utility and can provide an overall positive user experience in home settings. The study also demonstrates how combining a graded exercise program with all-day activity monitoring can provide insight into the potential for wearable systems to assess adherence to—and effectiveness of—home-based exercise programs on an individualized basis.
Background
Stroke is a leading cause of disability and a growing public health concern. Approximately 9.4 million Americans had a stroke between 2017 and 2020 (an overall prevalence of 3.3%, which is expected to increase to nearly 4% by 2030) [1]. An increasing population of individuals surviving stroke poses a significant burden on social, economic, and health care systems because motor impairments that limit movement on one side of the body affect up to 80% of survivors [2]. Motor impairments significantly degrade quality of life by hindering activities of daily living and limiting community participation. Deficits in motor function often result from physical impairment, but can also arise from the behavioral phenomenon of learned nonuse whereby limb use is suppressed despite sufficient motor capacity [3]. Prolonged nonuse can lead to weakness and contractures that further exacerbate impairment. Therefore, a primary goal of rehabilitation after stroke focuses on promoting recovery of impaired movements. Exercise training is an effective tool in restoring motor function, even beyond the acute stage of recovery wherein most of the practical gains are typically seen [4, 5].
Although physical and occupational therapists commonly prescribe home exercise programs to manage residual sensorimotor deficits after stroke, adherence rates can be low thereby limiting the patient’s potential recovery [6, 7]. Home-based tele-rehabilitation programs with therapists providing intermittent supervision of the patient may help mitigate adherence issues [7] and demonstrate potential functional benefits [8, 9] that equal or exceed those provided by conventional face-to-face therapy (for reviews see [10, 11]). Augmenting home-based tele-rehabilitation programs with wearable technologies that monitor movement and provide feedback to patients and therapists has potential to improve stroke outcomes through increased intensity of therapy and adherence to rehabilitation programs [12, 13]; see also [9]. Despite its promise, wearable activity monitoring technology is not widely used by therapists in day-to-day stroke care in the clinic [14] or by patients at home. Barriers to adoption include lack of skills and knowledge of patients, not knowing what brand and type of monitor to choose (cf. [15]), and the skills, beliefs, and attitudes of individual therapists, which determine the current use of wearable technology [14]. Other factors, including user motivation and trust in the technology likely contribute to patterns of low adherence (cf. [16, 17]).
In recognition of this opportunity, there has been a recent explosion in the number and types of technologies proposed to promote adherence to home-based exercise programs for physical rehabilitation after stroke [18,19,20,21,22,23,24,25,26,27,28,29], for reviews see [30,31,32]. Most of these systems use micro-electro-mechanical sensor (MEMS) technology such as accelerometers and gyroscopes to monitor body movements in real-time and to derive summary statistics such as “activity counts” [22, 33, 34] or measures of movement smoothness [23]. Other approaches to motion tracking are possible such as visual image processing systems cf. [35] but lack the portability and convenience of wearable systems.
The most common application of wearable technologies is the monitoring and assessment of the quantity and quality of movement [18, 26, 36,37,38,39,40]. Wearable technologies can also provide helpful cues (i.e., reminders, nudges) to perform activities such as exercises prescribed as therapy [19, 20, 24, 25, 27, 28, 41]. In one exemplar study, Holden and colleagues describe a wrist-worn system [24] that provided a vibratory stimulus to the more-involved arm when that arm’s activity level fell below a personalized threshold for a selected time window. If prompted, the participant was instructed to increase more-involved arm movements, ideally by performing pre-selected activities from a self-directed repetitive functional task practice program [19]. The study protocol also included twice weekly meetings with a study therapist to download acceleration data and to provide performance feedback to the participant. Across seven participants and the 4-week program, this system provided only a small number of cues per day (median = 4), although mean arm activity increased following prompts by 11% to 29%. The authors conclude that personalized prompts delivered by a wrist-worn accelerometer may enhance self-directed arm activity after stroke [19]. However, for technologies to be adopted by clinicians and their patients, the systems must not only have practical utility, but they must also provide a positive user experience within the context of their intended use scenarios cf. [20, 27, 29].
To date, wearable rehabilitation exercise systems have prompted users to increase activity relatively infrequently, such as once every 10 min [25], once an hour [24] or less frequently [24, 27]. User feedback indicates that they desire flexible exercise schedules and well-defined exercise recommendations with graded challenge levels based on ability [27]. In the current study, we sought to assess the utility, usability, and user experience of a wearable exercise cueing and monitoring system designed to promote high-dose (60 cues per 30-min exercise session, 3× per day), graded-challenge exercise at-home with a small cohort of hemiparetic stroke survivors. Our clinician-designed exercise program was motivated by the fact that many survivors of stroke are ineligible for interventions such as constraint-induced movement therapy (CIMT) [42, 43], which is suitable only for participants retaining substantial motor capacity (e.g., residual wrist extension). Our novel exercise program seeks to engage patients in high-dose activities while accepting of a broad range of impairment levels, ranging from an inability to move the more-involved arm and hand to the ability to move that limb independently. Our study included a wide age range of participants (29 to 63 years old), a wide range of time post-stroke (2 to 21 years), and varying living situations (i.e., living alone, living with family, or in assisted care settings) to demonstrate how such a system can be used by different populations. Quantitative movement data was derived from motion trackers worn on both wrists. End-user feedback was collected through well-validated quantitative surveys that assess key aspects of the subjective user experience. Additional qualitative feedback was collected through questionnaires and informal discussions designed to solicit recommendations for future system modifications or improvements. After summarizing our findings, we provide two individual case reports that demonstrate how patients with different levels of residual motor capacity chose to engage with the cued exercise program in their home setting.
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