Proactive Ethical Design for Neuroengineering, Assistive and Rehabilitation Technologies: the Cybathlon Lesson

Technologies for monitoring activities of daily living in older adults: a systematic review

PURPOSE

As the older adult population rise globally, technologies to monitoring activities of daily living (ADL) may have a role in supporting aging in place for older adults. The objective of this systematic literature review was to study the scope, diversity and readiness of technologies developed to monitor ADL in older adults.

METHODS

We systematically searched two scientific databases (CINAHL and IEEE), following Preferred Reporting Items for Systematic reviews and Meta Analyses (PRISMA) guidelines. We included studies on technologies used to monitor older adults' ADL in the home but excluded studies focused on communication technologies (phone calls, text messages) or monitoring postures alone. The JBI checklist for case series was used for quality assessment. Extracted details included population characteristics, ADL assessment outcomes, types of monitoring technology, and technology readiness and usability.

RESULTS

The search found 147 papers, with 16 papers included in the final analysis. The literature described 48 types of technologies. Of moderate quality studies, five studies used wearables at technology readiness level 4-6 to monitor basic ADL (walking, transfers and walking up stairs) and one used ambient sensors to detect urinary incontinence.

CONCLUSIONS

Monitoring technologies remain at development stages. More research is needed to strengthen technologies that monitor activities of daily living.

Home-based upper limb stroke rehabilitation mechatronics: challenges and opportunities

Interest in home-based stroke rehabilitation mechatronics, which includes both robots and sensor mechanisms, has increased over the past 12 years. The COVID-19 pandemic has exacerbated the existing lack of access to rehabilitation for stroke survivors post-discharge. Home-based stroke rehabilitation devices could improve access to rehabilitation for stroke survivors, but the home environment presents unique challenges compared to clinics. The present study undertakes a scoping review of designs for at-home upper limb stroke rehabilitation mechatronic devices to identify important design principles and areas for improvement. Online databases were used to identify papers published 2010-2021 describing novel rehabilitation device designs, from which 59 publications were selected describing 38 unique designs. The devices were categorized and listed according to their target anatomy, possible therapy tasks, structure, and features. Twenty-two devices targeted proximal (shoulder and elbow) anatomy, 13 targeted distal (wrist and hand) anatomy, and three targeted the whole arm and hand. Devices with a greater number of actuators in the design were more expensive, with a small number of devices using a mix of actuated and unactuated degrees of freedom to target more complex anatomy while reducing the cost. Twenty-six of the device designs did not specify their target users' function or impairment, nor did they specify a target therapy activity, task, or exercise. Twenty-three of the devices were capable of reaching tasks, 6 of which included grasping capabilities. Compliant structures were the most common approach of including safety features in the design. Only three devices were designed to detect compensation, or undesirable posture, during therapy activities. Six of the 38 device designs mention consulting stakeholders during the design process, only two of which consulted patients specifically. Without stakeholder involvement, these designs risk being disconnected from user needs and rehabilitation best practices. Devices that combine actuated and unactuated degrees of freedom allow a greater variety and complexity of tasks while not significantly increasing their cost. Future home-based upper limb stroke rehabilitation mechatronic designs should provide information on patient posture during task execution, design with specific patient capabilities and needs in mind, and clearly link the features of the design to users' needs.

Proactive and Ongoing Analysis and Management of Ethical Concerns in the Development, Evaluation, and Implementation of Smart Homes for Older Adults With Frailty

Successful adoption and sustained use of smart home technology can support the aging in place of older adults with frailty. However, the expansion of this technology has been limited, particularly by a lack of ethical considerations surrounding its application. This can ultimately prevent older adults and members of their support ecosystems from benefiting from the technology. This paper has 2 aims in the effort to facilitate adoption and sustained use: to assert that proactive and ongoing analysis and management of ethical concerns are crucial to the successful development, evaluation, and implementation of smart homes for older adults with frailty and to present recommendations to create a framework, resources, and tools to manage ethical concerns with the collaboration of older adults; members of their support ecosystems; and the research, technical development, clinical, and industry communities. To support our assertion, we reviewed intersecting concepts from bioethics, specifically principlism and ethics of care, and from technology ethics that are salient to smart homes in the management of frailty in older adults. We focused on 6 conceptual domains that can lead to ethical tensions and of which proper analysis is essential: privacy and security, individual and relational autonomy, informed consent and supported decision-making, social inclusion and isolation, stigma and discrimination, and equity of access. To facilitate the proactive and ongoing analysis and management of ethical concerns, we recommended collaboration to develop a framework with 4 proposed elements: a set of conceptual domains as discussed in this paper, along with a tool consisting of reflective questions to guide ethical deliberation throughout the project phases; resources comprising strategies and guidance for the planning and reporting of ethical analysis throughout the project phases; training resources to support leadership, literacy, and competency in project teams for the analysis and management of ethical concerns; and training resources for older adults with frailty, their support ecosystems, and the public to support their awareness and participation in teams and ethical analysis processes. Older adults with frailty require nuanced consideration when incorporating technology into their care because of their complex health and social status and vulnerability. Smart homes may have a greater likelihood of accommodating users and their contexts with committed and comprehensive analysis, anticipation, and management of ethical concerns that reflect the unique circumstances of these users. Smart home technology may then achieve its desired individual, societal, and economic outcomes and serve as a solution to support health; well-being; and responsible, high-quality care.

Considerations for at-home upper-limb rehabilitation technology following stroke: Perspectives of stroke survivors and therapists

Introduction

This study investigated the needs of stroke survivors and therapists, and how they may contrast, for the design of robots for at-home post stroke rehabilitation therapy, in the Ontario, Canada, context.

Methods

Individual interviews were conducted with stroke survivors (n = 10) and therapists (n = 6). The transcripts were coded using thematic analysis inspired by the WHO International Classification of Functioning, Disability, and Health.

Results

Design recommendations, potential features, and barriers were identified from the interviews. Stroke survivors and therapists agreed on many of the needs for at-home robotic rehabilitation; however, stroke survivors had more insights into their home environment, barriers, and needs relating to technology, while therapists had more insights into therapy methodology and patient safety and interaction. Both groups felt a one-size-fits-all approach to rehabilitation robot design is inappropriate. Designs could address a broader range of impairments by incorporating household items and breaking activities down into their component motions. Designs should incorporate hand and wrist supports and activities. Designs should monitor trunk and shoulder motion and consider incorporating group activities.

Conclusion

While therapists can provide insight in the early stages of design of rehabilitation technology, stroke survivors' perspectives are crucial to designing for the home environment.

Justice, Equity, Diversity, and Inclusion Curriculum Within an Introductory Bioengineering Course

Curriculum initiatives that provide the societal context of engineering practice can contribute to justice, equity, diversity, and inclusion (JEDI) within the profession, as well as within the communities served by engineers. JEDI curriculum can foster diversity and inclusion by acknowledging and addressing social justice issues, providing a safe and inclusive space for students' voices to be heard, and advancing a productive dialogue within their institution of higher learning. Furthermore, such curriculum initiatives can empower students with the theoretical frameworks, analytical tools, and knowledge base to recognize and address ethical challenges and opportunities related to justice, equity, diversity, and inclusion in their field. This Teaching Tips paper offers a description of a pilot program to incorporate JEDI material within a core bioengineering course modeled on evidence-based curriculum programs to embed ethics within technical courses. The author and collaborators sought to achieve two aims with the JEDI-focused material: (1) for students to learn how justice, equity, diversity, and inclusion intersect with bioengineering practice through an interdisciplinary lens of history, philosophy, sociology and anthropology which provide strong scholarly frameworks and theoretical foundations and (2) for students to participate in and foster an inclusive environment within their own educational institution through effectively communicating about these topics with each other. At the conclusion of the semester, a student survey indicated an overwhelmingly positive reception of the material. This paper will discuss the interdisciplinary curriculum development initiative, how the learning objectives were addressed by the specific lesson plans, and challenges to be addressed to create a sustainable educational model for the program.

The "humane in the loop": Inclusive research design and policy approaches to foster capacity building assistive technologies in the COVID-19 era

The COVID-19 pandemic is emerging as a driver of greater reliance on wireless technologies, including intelligent assistive technologies, such as robots and artificial intelligence. We must integrate the humane "into the loop" of human-AT interactions to realize the full potential of wireless inclusion for people with disabilities and older adults. Embedding ethics into these new technologies is critical and requires a co-design approach, with end users participating throughout. Developing humane AT begins with a participatory, user-centered design embedded in an iterative co-creation process, and guided by an ethos prioritizing beneficence, user autonomy and agency. To gain insight into plausible AT development pathways ("futures"), we use scenario planning as a tool to articulate themes in the research literature. Four plausible scenarios are developed and compared to identify one as a desired "humane" future for AT development. Policy and practice recommendations derived from this scenario, and their implications for the role of AT in the advancement of human potential are explored.

Socially assistive robotics and older family caregivers of young adults with Intellectual and Developmental Disabilities (IDD): A pilot study exploring respite, acceptance, and usefulness

Introduction

The need for caregiver respite is well-documented for the care of persons with IDD. Social Assistive Robotics (SAR) offer promise in addressing the need for caregiver respite through ‘complementary caregiving’ activities that promote engagement and learning opportunities for a care recipient (CR) with IDD. This study explored the acceptability and usefulness of a SAR caregiver respite program responsive to feedback from both young adults with IDD and their older family caregivers (age 55+).

Method

Young adults with IDD and caregiver dyads (N = 11) were recruited. A mixed methods research design was deployed in three phases: Phase I with four focus groups to inform the program design; Phase II for program demonstration and evaluation with pre- and post-surveys; and Phase III with post-program interviews for feedback and suggestions.

Results

Both young adults with IDD and their caregivers scored favorably the social presence of, social engagement, and satisfaction with robot Pepper. Though there was no significant improvement of caregiving burden/stress as well as well-being of the young adults with IDD based on surveys, results from interviews suggested that the SAR may offer physical/emotional respite to caregivers by providing companionship/friendship as well as promoting independence, safety/monitoring, and interactive engagement with children.

Discussion

SAR has potential in providing respite for older family caregivers. Future studies need a longer program design and larger sample size to develop a promising intervention and test its feasibility and efficacy.

Design of a wearable vibrotactile stimulation device for individuals with upper-limb hemiparesis and spasticity

Vibratory stimulation may improve post-stroke symptoms such as spasticity; however, current studies are limited by the large, clinic-based apparatus used to apply this stimulation. A wearable device could provide vibratory stimulation in a mobile form, enabling further study of this technique. An initial device, the vibrotactile stimulation (VTS) Glove, was deployed in an eight-week clinical study in which sixteen individuals with stroke used the device for several hours daily. Participants reported wearing the glove during activities such as church, social events, and dining out. However, 69% of participants struggled to extend or insert their fingers to don the device. In a follow-up study, eight individuals with stroke evaluated new VTS device prototypes in a three-round iterative design study with the aims of creating the next generation of VTS devices and understanding features that influence interaction with a wearable device by individuals with impaired upper-limb function. Interviews and interaction tasks were used to define actionable design revisions between each round of evaluation. Our analysis identified six new themes from participants regarding device designs: hand supination is challenging, separate finger attachments inhibit fit and use, fingers may be flexed or open, fabric coverage impacts comfort, a reduced concern for social comfort, and the affected hand is infrequently used. Straps that wrap around the arm and fixtures on the anterior arm were other challenging features. We discuss potential accommodations for these challenges, as well as social comfort. New VTS device designs are presented and were donned in an average time of 48 seconds.

A survey on the influence of CYBATHLON on the development and acceptance of advanced assistive technologies

Background

Advanced assistive technologies (AAT) aim to exploit the vast potential of technological developments made in the past decades to improve the quality of life of people with disabilities. Combining complex robotic technologies with the unique needs of people with disabilities requires a strong focus on user-centered design to ensure that the AAT appropriately addresses the daily life struggles of target users. The CYBATHLON aims to promote this mindset by empowering the AAT target users (“pilots”) to compete on race tracks that represent approximations of daily life obstacles. The objective of this work was to investigate the AAT technology development, usability, and user involvement (i.e., application of user-centered design) in the context of the CYBATHLON.

Methods

With an online survey targeting the pilots and technical leads of teams preparing for the CYBATHLON 2020 Global Edition, we investigated to what extent the pilots were involved in device development and how this influences the perceived usability of the showcased AAT. Furthermore, the effects of user-centered design variables on the individual race performances were analyzed.

Results

A total of 81 responses from 35 pilots and 46 technical leads were collected in the two weeks prior to the event. Of all teams partaking in the included disciplines of the CYBATHLON 2020 Global Edition, 81.8% (36 of 44) were included in the study. User-centered design appeared to be a prevalent practice among the teams, as 85.7% of all pilots reported a certain level of involvement. However, only 25.5% of the pilots reported daily life usage, despite QUEST usability scores of both respondent groups showing moderate to high satisfaction with the respected AAT across all investigated disciplines. An explorative linear mixed model indicated that daily life usage (p < 0.05) and prolonged user involvement (e.g., more than 2 years, p < 0.001) have a significant positive effect on the race performance at the competition.

Conclusions

We conclude that the CYBATHLON positively fulfills its conceptual goals of promoting active participation and inclusion of people with disabilities in the design and evaluation of AAT, thereby stimulating the development of promising novel technological solutions. Also, our data could underline the value of the competition as a benchmark, highlighting remaining usability limitations or technology adoption hurdles.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12984-022-01015-5.

Perspectives on Rehabilitation Using Non-invasive Brain Stimulation Based on Second-Person Neuroscience of Teaching-Learning Interactions

Recent advances in second-person neuroscience have allowed the underlying neural mechanisms involved in teaching-learning interactions to be better understood. Teaching is not merely a one-way transfer of information from teacher to student; it is a complex interaction that requires metacognitive and mentalizing skills to understand others’ intentions and integrate information regarding oneself and others. Physiotherapy involving therapists instructing patients on how to improve their motor skills is a clinical field in which teaching-learning interactions play a central role. Accumulating evidence suggests that non-invasive brain stimulation (NIBS) modulates cognitive functions; however, NIBS approaches to teaching-learning interactions are yet to be utilized in rehabilitation. In this review, I evaluate the present research into NIBS and its role in enhancing metacognitive and mentalizing abilities; I then review hyperscanning studies of teaching-learning interactions and explore the potential clinical applications of NIBS in rehabilitation. Dual-brain stimulation using NIBS has been developed based on findings of brain-to-brain synchrony in hyperscanning studies, and it is delivered simultaneously to two individuals to increase inter-brain synchronized oscillations at the stimulated frequency. Artificial induction of brain-to-brain synchrony has the potential to promote instruction-based learning. The brain-to-brain interface, which induces inter-brain synchronization by adjusting the patient’s brain activity, using NIBS, to the therapist’s brain activity, could have a positive effect on both therapist-patient interactions and rehabilitation outcomes. NIBS based on second-person neuroscience has the potential to serve as a useful addition to the current neuroscientific methods used in complementary interventions for rehabilitation.

Implementing Ethics in Healthcare AI-Based Applications: A Scoping Review

A number of Artificial Intelligence (AI) ethics frameworks have been published in the last 6 years in response to the growing concerns posed by the adoption of AI in different sectors, including healthcare. While there is a strong culture of medical ethics in healthcare applications, AI-based Healthcare Applications (AIHA) are challenging the existing ethics and regulatory frameworks. This scoping review explores how ethics frameworks have been implemented in AIHA, how these implementations have been evaluated and whether they have been successful. AI specific ethics frameworks in healthcare appear to have a limited adoption and they are mostly used in conjunction with other ethics frameworks. The operationalisation of ethics frameworks is a complex endeavour with challenges at different levels: ethics principles, design, technology, organisational, and regulatory. Strategies identified in this review are proactive, contextual, technological, checklist, organisational and/or evidence-based approaches. While interdisciplinary approaches show promises, how an ethics framework is implemented in an AI-based Healthcare Application is not widely reported, and there is a need for transparency for trustworthy AI.

The Time Is Now: A FASTER Approach to Generate Research Evidence for Technology-Based Interventions in the Field of Disability and Rehabilitation

Current approaches for generating high-quality research evidence for technology-based interventions in the field of disability and rehabilitation are inappropriate. Prevailing approaches often focus on randomized controlled trials as standard and apply clinical trial practices designed for pharmaceuticals; such approaches are unsuitable for technology-based interventions and are counterproductive to the goals of supporting people with disabilities and creating benefits for society. This communication is designed to: (1) advocate for the use of alternative approaches to generating evidence in the development and evaluation of technology-based interventions; (2) propose an alternative framework and guiding principles; and (3) stimulate action by multiple disciplines and sectors to discuss, adopt, and promote alternative approaches. Our Framework for Accelerated and Systematic Technology-based intervention development and Evaluation Research (FASTER) is informed by established innovation design processes, complex intervention development, evaluation, and implementation concepts as well as our collective experiences in technology-based interventions research and clinical rehabilitation practice. FASTER is intended to be meaningful, timely, and practical for researchers, technology developers, clinicians, and others who develop these interventions and seek evidence. We incorporate research methods and designs that better align with creating technology-based interventions and evidence for integration into practice. We propose future activities to improve the generation of research evidence, enable the selection of research methods and designs, and create standards for evidence evaluation to support rigor and applicability for technology-based interventions. With this communication we aim to improve and advance technology-based intervention integration from conception to use, thus responsibly accelerating innovation to have greater positive benefit for people and society.

Artificial Intelligence in Clinical Neuroscience: Methodological and Ethical Challenges

Clinical neuroscience is increasingly relying on the collection of large volumes of differently structured data and the use of intelligent algorithms for data analytics. In parallel, the ubiquitous collection of unconventional data sources (e.g. mobile health, digital phenotyping, consumer neurotechnology) is increasing the variety of data points. Big data analytics and approaches to Artificial Intelligence (AI) such as advanced machine learning are showing great potential to make sense of these larger and heterogeneous data flows. AI provides great opportunities for making new discoveries about the brain, improving current preventative and diagnostic models in both neurology and psychiatry and developing more effective assistive neurotechnologies. Concurrently, it raises many new methodological and ethical challenges. Given their transformative nature, it is still largely unclear how AI-driven approaches to the study of the human brain will meet adequate standards of scientific validity and affect normative instruments in neuroethics and research ethics. This manuscript provides an overview of current AI-driven approaches to clinical neuroscience and an assessment of the associated key methodological and ethical challenges. In particular, it will discuss what ethical principles are primarily affected by AI approaches to human neuroscience, and what normative safeguards should be enforced in this domain.

Psychosis, vulnerability, and the moral significance of biomedical innovation in psychiatry. Why ethicists should join efforts

The study of the neuroscience and genomics of mental illness are increasingly intertwined. This is mostly due to the translation of medical technologies into psychiatry and to technological convergence. This article focuses on psychosis. I argue that the convergence of neuroscience and genomics in the context of psychosis is morally problematic, and that ethics scholarship should go beyond the identification of a number of ethical, legal, and social issues. My argument is composed of two strands. First, I argue that we should respond to technological convergence by developing an integrated, patient-centred approach focused on the assessment of individual vulnerabilities. Responding to technological convergence requires that we (i) integrate insights from several areas of ethics, (ii) translate bioethical principles into the mental health context, and (iii) proactively try to anticipate future ethical concerns. Second, I argue that a nuanced understanding of the concept of vulnerability might help us to accomplish this task. I borrow Florencia Luna's notion of 'layers of vulnerability' to show how potential harms or wrongs to individuals who experience psychosis can be conceptualised as stemming from different sources, or layers, of vulnerability. I argue that a layered notion of vulnerability might serve as a common ground to achieve the ethical integration needed to ensure that biomedical innovation can truly benefit, and not harm, individuals who suffer from psychosis.

Assistive Technologies: Social Barriers and Socio-Technical Pathways

Against the background of recent international regulation, the role of assistive technologies in the fields of independent living, education, and employment is analyzed in this article to propose a future strategy for a socio-technical perspective on their further development processes. Based on qualitative expert interviews at the European level, the role and scope of ATs in these fields are described for three types of disabilities: visual impairment, hearing impairment, and autism spectrum disorder. The findings show that digitalization processes entail major opportunities and challenges for ATs in all three fields and that further measures are needed to bring technical opportunities to their full potential in adverse social contexts. Regarding future technology development, the authors propose a development strategy focusing strongly on the social context of the devices. Only in this manner, relevant “unintended consequences”, as well as social or ethical concerns, can be identified and addressed.

User-centered Design and Evaluation of Physical Interfaces for an Exoskeleton for Paraplegic Users

Over the last decade, the use of wearable exoskeletons for human locomotion assistance has become more feasible. The VariLeg powered lower limb robotic exoskeleton is an example of such systems, potentially enabling paraplegic users to perform upright activities of daily living. The acceptance of this type of robotic assistive technologies is often still affected by limited usability, in particular regarding the physical interface between the exoskeleton and the user (here referred to as pilot). In this study, we proposed and evaluated a novel pilot attachment system (PAS), which was designed based on user-centered design with experienced paraplegic exoskeleton users. Subjective assessments to compare usability aspects of the initial and the redesigned physical interfaces were conducted with two paraplegic and five healthy pilots. The redesigned PAS showed a 45% increase in the system usability scale (SUS), normalized to the PAS of a commercial exoskeleton assessed in the same manner. Pain rating scales assessed with healthy pilots indicated an increased comfort using the redesigned PAS while performing several activities of daily living. Overall, an improvement in usability relative to the initial PAS was achieved through intensified user evaluation and individual needs assessments. Hence, a user-centered design of physical body-machine interfaces has the potential to positively influence the usability and acceptance of lower limb exoskeletons for paraplegic users.

HabITec: A Sociotechnical Space for Promoting the Application of Technology to Rehabilitation

Society is currently facing unprecedented technological advances that simultaneously create opportunities and risks. Technology has the potential to revolutionize rehabilitation and redefine the way we think about disability. As more advanced technology becomes available, impairments and the environmental barriers that engender disability can be significantly mitigated. The opportunity to apply technology to rehabilitation following serious injuries or illnesses is becoming more evident. However, the translation of these innovations into practice remains limited and often inequitable. This situation is exacerbated by the fact that not all relevant parties are involved in the decision-making process. Our solution was to create a sociotechnical system, known as HabITec, where people with disabilities, practitioners, funders, researchers, designers and developers can work together and co-create new solutions. Sociotechnical thinking is collaborative, interdisciplinary, adaptive, problem-solving and focused on a shared set of goals. By applying a sociotechnical approach to the healthcare sector, we aimed to minimize the lag in translating new technologies into rehabilitation practice. This collaborative co-design process supports innovation and ensures that technological solutions are practical and meaningful, ethical, sustainable and contextualized. In this conceptual paper, we presented the HabITec model along with the empirical evidence and theories on which it has been built.

JNER at 15 years: analysis of the state of neuroengineering and rehabilitation

On JNER's 15th anniversary, this editorial analyzes the state of the field of neuroengineering and rehabilitation. I first discuss some ways that the nature of neurorehabilitation research has evolved in the past 15 years based on my perspective as editor-in-chief of JNER and a researcher in the field. I highlight increasing reliance on advanced technologies, improved rigor and openness of research, and three, related, new paradigms - wearable devices, the Cybathlon competition, and human augmentation studies - indicators that neurorehabilitation is squarely in the age of wearability. Then, I briefly speculate on how the field might make progress going forward, highlighting the need for new models of training and learning driven by big data, better personalization and targeting, and an increase in the quantity and quality of usability and uptake studies to improve translation.

Progress in Neuroengineering for brain repair: New challenges and open issues

Background

In recent years, biomedical devices have proven to be able to target also different neurological disorders. Given the rapid ageing of the population and the increase of invalidating diseases affecting the central nervous system, there is a growing demand for biomedical devices of immediate clinical use. However, to reach useful therapeutic results, these tools need a multidisciplinary approach and a continuous dialogue between neuroscience and engineering, a field that is named neuroengineering. This is because it is fundamental to understand how to read and perturb the neural code in order to produce a significant clinical outcome.

Results

In this review, we first highlight the importance of developing novel neurotechnological devices for brain repair and the major challenges expected in the next years. We describe the different types of brain repair strategies being developed in basic and clinical research and provide a brief overview of recent advances in artificial intelligence that have the potential to improve the devices themselves. We conclude by providing our perspective on their implementation to humans and the ethical issues that can arise.

Conclusions

Neuroengineering approaches promise to be at the core of future developments for clinical applications in brain repair, where the boundary between biology and artificial intelligence will become increasingly less pronounced.