Assistive Technology for the Upper Extremities After Stroke: Systematic Review of Users' Needs

Assistive Technology utilization among stroke survivors in Kano, Northwest Nigeria: A cross-sectional study

Mobility impairments and participation restrictions are common occurrences post-stroke, which may necessitate the need to utilize Assistive Technology (AT). This study investigated the prevalence, pattern, and satisfaction with AT utilization in stroke survivors (SS). The study was conducted in two hospitals in Kano, Nigeria. The QUBEC user evaluation of satisfaction with AT (QUEST) questionnaire and the Rivermead Mobility Index were used to assess satisfaction with AT utilization and mobility, respectively. Pearson correlation and independent t-test were used to determine the relationship and gender difference among the outcomes, respectively. A total of 280 SS participated; however, only 115 (41.07%) were AT users. The commonly used AT was wheelchair 84 (73%), while the least used was walking frame 3 (2.6%). About two-thirds of the participants were quite or very satisfied with their ATs. The duration of AT utilization is positively related to stroke duration (r = 0.940) but negatively related to mobility level (r = -0.246). There is no significant gender difference in duration and satisfaction with AT utilization. AT like wheelchairs seems uncommonly utilized among SS in Kano, Nigeria, likely due to patients' lack of knowledge of use, economic factors, and culture among others.

Can a previously co-designed device be used by others? A service evaluation of the use of the Sativex spray holder for individuals with multiple sclerosis

PURPOSE

Co-design has previously been used to design custom assistive devices, involving the end user in the process to ensure the device meets their needs. From devices previously created, designs could be re-used and modified to meet variations in the needs of other individuals with similar clinical needs. This service evaluation explored the re-usability of a holder for helping administer the spray medication Sativex, for individuals with multiple sclerosis.

METHODS

This evaluation was conducted in a UK based Rehabilitation Engineering NHS department. Five individuals who were currently prescribed Sativex trialled the device and provided feedback to further customise the device. Questionnaires evaluated the satisfaction and impact of the devices provided. The resources to provide the devices were calculated.

RESULTS

Three of the five individuals who trialled the Sativex spray holder were using long term. Modifications to the shape of the holder were made due to differences in hand strength and dexterity from the initial user. Results indicated high satisfaction with the device and service provided, with improvements in the individuals' competence, adaptability and self-esteem. The mean cost of providing and modifying the device was £78.62.

CONCLUSIONS

The previously co-designed Sativex spray holder was used by other individuals, demonstrating how a co-design framework can be used to identify user needs and modifications to previous designs and then implement design changes. The wider use of the device helped off-set the initial costs associated with co-designing devices. Further work is required to explore how other devices could be modified to meet individual needs.

Effects of 3D-printed assistive device on daily life function in patients with neurological impairment: a pilot study

PURPOSE

To explore the effects of customized 3D-printed assistive technology (AT) on functional performance and feasibility in patients with neurological impairment.

METHODS

Patients with neurological impairment were recruited and randomized into customized 3D-printed assistive device group (group 1; n = 17) or standard device group (group 2; n = 14). The device was designed to assist their writing, spoon using, and typing. Each patient underwent 4-week intervention with the device (30 min per session, twice a week).

RESULTS

We observed significant differences in shoulder abduction (p = .00), external rotation (p = .01), and internal rotation (p = .02) in group 1. And significant differences in abduction (p = .05) and external rotation (p = .05) between the 2 groups. Group 1 achieved significant improvements in writing without AT (p = .04) and with AT (p = .02), spoon use without AT (p = .02) and with AT (p = .03), and hemiplegia-side typing with AT (p = .00). Group 2 achieved significant improvements in writing without AT (p = .01), hemiplegia-side typing without AT (p = .01), and bil-side typing with AT (P = .05). Moreover, no significant differences were noted in other outcome measures.

CONCLUSIONS

This study demonstrated that customized 3D-printed AT can improve shoulder active motion for patients with neurological impairment. A positive effect in functional hand tasks after AT intervention. Offering customized AT with specific training could enhance the efficacy of interventions. The feasibility of using 3D printing technology to produce customized AT, which has the potential to be cost-effective and efficient.

Decoding hand and wrist movement intention from chronic stroke survivors with hemiparesis using a user-friendly, wearable EMG-based neural interface

OBJECTIVE

Seventy-five percent of stroke survivors, caregivers, and health care professionals (HCP) believe current therapy practices are insufficient, specifically calling out the upper extremity as an area where innovation is needed to develop highly usable prosthetics/orthotics for the stroke population. A promising method for controlling upper extremity technologies is to infer movement intention non-invasively from surface electromyography (EMG). However, existing technologies are often limited to research settings and struggle to meet user needs.

APPROACH

To address these limitations, we have developed the NeuroLife® EMG System, an investigational device which consists of a wearable forearm sleeve with 150 embedded electrodes and associated hardware and software to record and decode surface EMG. Here, we demonstrate accurate decoding of 12 functional hand, wrist, and forearm movements in chronic stroke survivors, including multiple types of grasps from participants with varying levels of impairment. We also collected usability data to assess how the system meets user needs to inform future design considerations.

MAIN RESULTS

Our decoding algorithm trained on historical- and within-session data produced an overall accuracy of 77.1 ± 5.6% across 12 movements and rest in stroke participants. For individuals with severe hand impairment, we demonstrate the ability to decode a subset of two fundamental movements and rest at 85.4 ± 6.4% accuracy. In online scenarios, two stroke survivors achieved 91.34 ± 1.53% across three movements and rest, highlighting the potential as a control mechanism for assistive technologies. Feedback from stroke survivors who tested the system indicates that the sleeve's design meets various user needs, including being comfortable, portable, and lightweight. The sleeve is in a form factor such that it can be used at home without an expert technician and can be worn for multiple hours without discomfort.

SIGNIFICANCE

The NeuroLife EMG System represents a platform technology to record and decode high-resolution EMG for the real-time control of assistive devices in a form factor designed to meet user needs. The NeuroLife EMG System is currently limited by U.S. federal law to investigational use.

Assessing the use of co-design to produce bespoke assistive technology solutions within a current healthcare service: a service evaluation

PURPOSE

Co-design involves engaging with the end-user in the design process and may help reduce the barriers to assistive technology use. Previous research has used co-design in the provision of assistive technology, but no research has looked at applying it within a healthcare setting. This service evaluation examines the use of co-design in providing customized assistive devices within a current UK healthcare based Rehabilitation Engineering department.

METHODS

This evaluation reports on three case studies. Individuals identified a range of challenges in daily living. The participants worked with the clinician in trialling prototypes and providing feedback to develop custom devices. A mixed-method approach of questionnaires and semi-structured interviews were used to evaluate the devices provided and the co-design approach. The resources required to provide the device were also calculated.

RESULTS

Five different devices were developed, which were able to overcome the challenges identified. Results indicated participants were satisfied with both the devices and service provided. Participants expressed other benefits including increased independence, increased positive emotions and reduced mental load. Participants indicated they liked being involved in the design process and their feedback helped ensure the devices were customized to their needs.

CONCLUSIONS

The use of co-design was able to produce customized assistive device that met the needs of the individuals within a current healthcare service. Further work is required to assess the feasibility of utilising a co-design approach for the provision of other custom assistive technology in the future and explore if this can overcome the barriers to assistive technology use.Implications for rehabilitationEnd-user involvement, the design process can help enable customized assistive devices to be provided that better meet the user's needs.The custom assistive devices provided not only helped the individuals overcome the challenges identified but had wider reaching benefits for the individuals physical and mental health and wellbeing.End-users valued being able to input into the co-design process and working closely with the clinician in developing the device.

Mixed methods usability evaluation of an assistive wearable robotic hand orthosis for people with spinal cord injury

BACKGROUND

Robotic hand orthoses (RHO) aim to provide grasp assistance for people with sensorimotor hand impairment during daily tasks. Many of such devices have been shown to bring a functional benefit to the user. However, assessing functional benefit is not sufficient to evaluate the usability of such technologies for daily life application. A comprehensive and structured evaluation of device usability not only focusing on effectiveness but also efficiency and satisfaction is required, yet often falls short in existing literature. Mixed methods evaluations, i.e., assessing a combination of quantitative and qualitative measures, allow to obtain a more holistic picture of all relevant aspects of device usability. Considering these aspects already in early development stages allows to identify design issues and generate generalizable benchmarks for future developments.

METHODS

We evaluated the short-term usability of the RELab tenoexo, a RHO for hand function assistance, in 15 users with tetraplegia after a spinal cord injury through a comprehensive mixed methods approach. We collected quantitative data using the Action Research Arm Test (ARAT), the System Usability Scale (SUS), and timed tasks such as the donning process. In addition, qualitative data were collected through semi-structured interviews and user observations, and analyzed with a thematic analysis to enhance the usability evaluation. All insights were attributed and discussed in relation to specifically defined usability attributes such as comfort, ease of use, functional benefit, and safety.

RESULTS

The RELab tenoexo provided an immediate functional benefit to the users, resulting in a mean improvement of the ARAT score by 5.8 points and peaking at 15 points improvement for one user (clinically important difference: 5.7 points). The mean SUS rating of 60.6 represents an adequate usability, however, indicating that especially the RHO donning (average task time = 295 s) was perceived as too long and cumbersome. The participants were generally very satisfied with the ergonomics (size, dimensions, fit) of the RHO. Enhancing the ease of use, specifically in donning, increasing the provided grasping force, as well as the availability of tailoring options and customization were identified as main improvement areas to promote RHO usability.

CONCLUSION

The short-term usability of the RELab tenoexo was thoroughly evaluated with a mixed methods approach, which generated valuable data to improve the RHO in future iterations. In addition, learnings that might be transferable to the evaluation and design of other RHO were generated, which have the potential to increase the daily life applicability and acceptance of similar technologies.

Clinicians' perspectives and usage of rehabilitation technology: a survey

PURPOSE

The aim of this study was to investigate clinicians' perspectives regarding their usage of rehabilitation technology in their day-to-day practice and uncover the factors that impact clinicians' use of rehabilitation technology in their daily practice.

MATERIALS AND METHODS

An online survey was used to gather cross-sectional data from American occupational therapists, occupational therapy assistants, physical therapists, physical therapy assistants, and speech language pathologists. This survey used Likert-scale, multiple choice, and free-response questions.

RESULTS

Approximately half (n = 56/105, 53.3%) of our clinicians reported using rehabilitation in their daily practice. Less than 20% (n = 18/105, 17.1%) of the respondents strongly agreed that they felt comfortable implementing new rehabilitation technology, and few reported that their workplace encouraged (n = 16/85, 18.8%) or strongly encouraged (n = 14/85, 16.5%) the use of rehabilitation technology in practice. Additionally, excluding the 2011-2020 graduate clinicians that reported that they had not learned about rehabilitation technology in school or fieldwork, few reported feeling prepared (n = 14/97, 14.4%) or very prepared (n = 4/97, 4.1%) to use rehabilitation technology after graduation.

CONCLUSIONS

Our findings have revealed a sizable knowledge-to-practice gap in regard to clinicians' preparedness to engage with and advocate for rehabilitation technology in their day-to-day practice.

A metric for characterizing the arm nonuse workspace in poststroke individuals using a robot arm

An overreliance on the less-affected limb for functional tasks at the expense of the paretic limb and in spite of recovered capacity is an often-observed phenomenon in survivors of hemispheric stroke. The difference between capacity for use and actual spontaneous use is referred to as arm nonuse. Obtaining an ecologically valid evaluation of arm nonuse is challenging because it requires the observation of spontaneous arm choice for different tasks, which can easily be influenced by instructions, presumed expectations, and awareness that one is being tested. To better quantify arm nonuse, we developed the bimanual arm reaching test with a robot (BARTR) for quantitatively assessing arm nonuse in chronic stroke survivors. The BARTR is an instrument that uses a robot arm as a means of remote and unbiased data collection of nuanced spatial data for clinical evaluations of arm nonuse. This approach shows promise for determining the efficacy of interventions designed to reduce paretic arm nonuse and enhance functional recovery after stroke. We show that the BARTR satisfies the criteria of an appropriate metric for neurorehabilitative contexts: It is valid, reliable, and simple to use.

An evaluation of 3D printable elastics for post stroke dynamic hand bracing: a pilot study

The rise of 3D printing allows unprecedented customization of rehabilitation devices, and with an ever-expanding library of 3D printable (3DP) materials, the spectrum of attenable rehabilitation devices is likewise expanding. The current pilot study explores feasibility of using 3DP elastic materials to create dynamic hand orthoses for stroke survivors. A dynamic orthosis featuring a replaceable finger component was fabricated using 3DP elastic materials. Duplicates of the finger component were printed using different materials ranging from low stiffness (low elastic modulus) to relatively high stiffness (high elastic modulus). Five stroke survivors with predominantly moderate hand impairment were recruited to evaluate usability and impact of orthoses on upper extremity function and biomechanics. No significant differences in usability were found between 3D-printed orthoses and a commercial orthosis. Increases in stiffness of the 3DP material reduced pincer force (p = .0041) and the BBT score (p = .043). In comparison, the commercial orthosis did not reduce pincer force but may reduce BBT score to a degree that is clinically significant (p = .0002). While preliminary, these findings suggest that a dynamic orthosis is a feasible clinical application of 3DP elastic materials, and future study is warranted.

Understanding stroke survivors' preferences regarding wearable sensor feedback on functional movement: a mixed-methods study

BACKGROUND

In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors' preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine the ease of understanding and movement encouragement of feedback based on wearable sensor data (both arm/hand use and mobility) for stroke survivors and to identify preferences for feedback metrics (mode, content, frequency, and timing).

METHODS

A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of feedback about arm/hand use, step counts and gait symmetry. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change.

RESULTS

Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: (1) Motivation for behavior change, (2) Real-time feedback based on individual goals, and (3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting.

CONCLUSION

The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment.

Co-designing an interactive artificial intelligent system with post-stroke patients and caregivers to augment the lost abilities and improve their quality of life: a human-centric approach

Objectives

The motor disability due to stroke compromises the autonomy of patients and caregivers. To support autonomy and other personal and social needs, trustworthy, multifunctional, adaptive, and interactive assistive devices represent optimal solutions. To fulfill this aim, an artificial intelligence system named MAIA would aim to interpret users' intentions and translate them into actions performed by assistive devices. Analyzing their perspectives is essential to develop the MAIA system operating in harmony with patients' and caregivers' needs as much as possible.

Methods

Post-stroke patients and caregivers were interviewed to explore the impact of motor disability on their lives, previous experiences with assistive technologies, opinions, and attitudes about MAIA and their needs. Interview transcripts were analyzed using inductive thematic analysis.

Results

Sixteen interviews were conducted with 12 post-stroke patients and four caregivers. Three themes emerged: (1) Needs to be satisfied, (2) MAIA technology acceptance, and (3) Perceived trustfulness. Overall, patients are seeking rehabilitative technology, contrary to caregivers needing assistive technology to help them daily. An easy-to-use and ergonomic technology is preferable. However, a few participants trust a system based on artificial intelligence.

Conclusion

An interactive artificial intelligence technology could help post-stroke patients and their caregivers to restore motor autonomy. The insights from participants to develop the system depends on their motor ability and the role of patients or caregiver. Although technology grows exponentially, more efforts are needed to strengthen people's trust in advanced technology.

Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study

BACKGROUND

Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential.

OBJECTIVE

We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption.

METHODS

A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption).

RESULTS

The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007).

CONCLUSIONS

This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.

Acceptance of Assistive Technology by Users with Motor Disabilities Due to Spinal Cord or Acquired Brain Injuries: A Systematic Review

Acquired motor limits can be provoked by neurological lesions. Independently of the aetiologies, the lesions require patients to develop new coping strategies and adapt to the changed motor functionalities. In all of these occasions, what is defined as an assistive technology (AT) may represent a promising solution. The present work is a systematic review of the scientific AT-related literature published in the PubMed, Cinahl, and Psychinfo databases up to September 2022. This review was undertaken to summarise how the acceptance of AT is assessed in people with motor deficits due to neurological lesions. We review papers that (1) dealt with adults (≥18 years old) with motor deficits due to spinal cord or acquired brain injuries and (2) concerned user acceptance of hard AT. A total of 615 studies emerged, and 18 articles were reviewed according to the criteria. The constructs used to assess users' acceptance mainly entail people's satisfaction, ease of use, safety and comfort. Moreover, the acceptance constructs varied as a function of participants' injury severity. Despite the heterogeneity, acceptability was mainly ascertained through pilot and usability studies in laboratory settings. Furthermore, ad-hoc questionnaires and qualitative methods were preferred to unstandardized protocols of measurement. This review highlights the way in which people living with acquired motor limits greatly appreciate ATs. On the other hand, methodological heterogeneity indicates that evaluation protocols should be systematized and finely tuned.

Experimental Evaluation of EMKEY: An Assistive Technology for People with Upper Limb Disabilities

Assistive technology can help people with disabilities to use computers more effectively and can enable them to access the same information and resources as people without disabilities. To obtain more insight into the factors that can bring about the design of an Emulator of Mouse and Keyboard (EMKEY) to higher levels of user satisfaction, an experimental study was conducted in order to analyse its effectiveness and efficiency. The experimental study involved 27 participants (M_age = 20.81, SD = 1.14) who performed three experimental games under different conditions (using the mouse and using EMKEY with head movements and voice commands). According to the results, the use of EMKEY allowed for the successful performance of tasks such as matching stimuli (F_(2,78) = 2.39, p = 0.10, η² = 0.06). However, the execution times of a task were found to be higher when using the emulator to drag an object on the screen (t_(52,1) = -18.45, p ≤ 0.001, d = 9.60). These results indicate the effectiveness of technological development for people with upper limb disabilities; however, there is room for improvement in terms of efficiency. The findings are discussed in relation to previous research and are based on future studies aimed at improving the operation of the EMKEY emulator.

Understanding preferences of stroke survivors for feedback provision about functional movement behavior from wearable sensors: a mixed-methods study

Background

In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors' preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine stroke survivors' satisfaction with feedback from wearable sensors (both mobility and arm/hand use) and to identify preferences for feedback type and delivery schedule.

Methods

A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of quantitative and qualitative feedback. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change.

Results

Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: 1) Motivation for behavior change, 2) Real-time feedback based on individual goals, and 3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting.

Conclusion

The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment-one where stroke survivors live their lives.

Neuro-cognitive assessment of intentional control methods for a soft elbow exosuit using error-related potentials

Soft exosuits offer promise to support users in everyday workload tasks by providing assistance. However, acceptance of such systems remains low due to the difficulty of control compared with rigid mechatronic systems. Recently, there has been progress in developing control schemes for soft exosuits that move in line with user intentions. While initial results have demonstrated sufficient device performance, the assessment of user experience via the cognitive response has yet to be evaluated. To address this, we propose a soft pneumatic elbow exosuit designed based on our previous work to provide assistance in line with user expectations utilizing two existing state-of-the-art control methods consisting of a gravity compensation and myoprocessor based on muscle activation. A user experience study was conducted to assess whether the device moves naturally with user expectations and the potential for device acceptance by determining when the exosuit violated user expectations through the neuro-cognitive and motor response. Brain activity from electroencephalography (EEG) data revealed that subjects elicited error-related potentials (ErrPs) in response to unexpected exosuit actions, which were decodable across both control schemes with an average accuracy of 76.63 ± 1.73% across subjects. Additionally, unexpected exosuit actions were further decoded via the motor response from electromyography (EMG) and kinematic data with a grand average accuracy of 68.73 ± 6.83% and 77.52 ± 3.79% respectively. This work demonstrates the validation of existing state-of-the-art control schemes for soft wearable exosuits through the proposed soft pneumatic elbow exosuit. We demonstrate the feasibility of assessing device performance with respect to the cognitive response through decoding when the device violates user expectations in order to help understand and promote device acceptance.

Design of Spiral-Cable Forearm Exoskeleton to Assist Supination for Hemiparetic Stroke Subjects

We present the development of a cable-based passive forearm exoskeleton that is designed to assist supination for hemiparetic stroke survivors. Our device uniquely provides torque sufficient for counteracting spasticity within a below-elbow apparatus. The mechanism consists of a spiral single-tendon routing embedded in a rigid forearm brace and terminated at the hand and upper-forearm. A spool with an internal releasable-ratchet mechanism allows the user to manually retract the tendon and rotate the hand to counteract involuntary pronation synergies due to stroke. We characterize the mechanism with benchtop testing and five healthy subjects, and perform a preliminary assessment of the exoskeleton with a single chronic stroke subject having minimal supination ability. The mechanism can be integrated into an existing active hand-opening orthosis to enable supination support during grasping tasks, and also allows for a future actuated supination strategy.

Towards Unsupervised Rehabilitation: Development of a Portable Compliant Device for Sensorimotor Hand Rehabilitation

Sensorimotor impairments of the hand after stroke can drastically reduce the ability to perform activities of daily living. Recently, there has been an increased interest in minimally supervised and unsupervised rehabilitation to increase therapy dosage and to complement conventional therapy. Several devices have been developed that are simple to use and portable. Yet, they do not incorporate diversified somatosensory feedback, which has been suggested to promote sensorimotor recovery. Here we present the prototype of a portable one-degree-of-freedom hand trainer based on a novel compliant shell mechanism. Our solution is safe, intuitive, and can be used for various hand sizes. Importantly, it also provides rich sensory feedback through haptic rendering. We complement our device with a rehabilitation game, where we leverage interactive tangible game elements with diverse haptic characteristics to provide somatosensory training and foster recovery.

A Novel Mixed-Method Approach to Identify Needs and Requirements for Upper Limb Assistive Technology for Persons after Stroke

Following stroke, a significant portion of individuals suffer from upper limb impairments and struggle with activities of daily living. Dedicated assistive technology (AT), such as robotic hand orthoses (RHO), can help facilitate upper limb usage and allow users to regain independence in their daily lives. Often, users' needs and requirements are neglected in AT design, thereby contributing to poor technology acceptance. In this work, we propose and apply a mixed-method focus group combining qualitative and quantitative components to gather user expectations in view of a user-centred redesign of a RHO. Three main themes emerged from a thematic analysis of two focus groups (n=5): Experience after stroke, desired design features, and reflections and realisations. Participants listed device features they would look for in AT and ranked them relative to what they deem important and necessary for a satisfactory device. Participants primarily looked for AT that is effective, intuitive and easy to use. These insights complement traditional technical design requirements for RHO by considering user desires, aspects unfortunately often neglected in the early design process. This work provides guidelines allowing for the optimization of AT design to better match the needs of persons after stroke and improve technology acceptance.

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.

Exploring the barriers to using assistive technology for individuals with chronic conditions: a meta-synthesis review

PURPOSE

Assistive technology can provide a key tool to enabling independence, greater inclusion and participation in society for individuals with chronic conditions. This potential is currently not always realized due to barriers to accessing and using assistive technology. This review aims to identify the common barriers to acquiring and using assistive technology for users with chronic conditions through a systematic meta-synthesis. This differs from other systematic reviews by applying a transdiagnostic approach to identify if barriers are common across chronic conditions.

MATERIALS AND METHODS

A systematic literature search of five scientific databases (PubMed, SCOPUS, PsycINFO, CINAHL and Medline) was conducted to identify relevant qualitative studies. The search was conducted in November 2019. For the identified articles, thematic content analysis was conducted and the methodological quality was evaluated using the Critical Appraisal Skills Programme (CASP) checklist for qualitative research.

RESULTS

Forty papers met the inclusion criteria and were included in the analysis. Fifty-one descriptive themes grouped into six overarching analytical themes were identified from the studies. The analytical themes identified were: the design and function of the assistive technology, service provision, information and awareness, psychological barriers, support network and societal barriers.

CONCLUSIONS

The barriers are interconnected and common across different health conditions. More involvement in personalized care for developing strategies, adaptation of home technologies and provision of assistive technology could overcome the service provision and design barriers to assistive technology. Accessible information and providing greater awareness will be important to overcoming information, psychological and societal barriers to assistive technology.Implications for rehabilitationIndividuals with chronic conditions face complex barriers to acquiring and using assistive technology as a result of the devices themselves, their individual context, the healthcare context where assistive technology is provided and wider societal barriers.The provision of assistive technology needs to change away from the traditional medical model of the "expert" clinician and instead focus on more user involvement to deliver personalised care that utilises the users lived knowledge and experiences.Assistive technology provision should be considered alongside how to adapt everyday mainstream technology to meet user needs; the provision of devices should encourage creative problem solving rather then relying on pre-defined prescription lists of assistive technology.

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.

Intention Detection Strategies for Robotic Upper-Limb Orthoses: A Scoping Review Considering Usability, Daily Life Application, and User Evaluation

Wearable robotic upper limb orthoses (ULO) are promising tools to assist or enhance the upper-limb function of their users. While the functionality of these devices has continuously increased, the robust and reliable detection of the user's intention to control the available degrees of freedom remains a major challenge and a barrier for acceptance. As the information interface between device and user, the intention detection strategy (IDS) has a crucial impact on the usability of the overall device. Yet, this aspect and the impact it has on the device usability is only rarely evaluated with respect to the context of use of ULO. A scoping literature review was conducted to identify non-invasive IDS applied to ULO that have been evaluated with human participants, with a specific focus on evaluation methods and findings related to functionality and usability and their appropriateness for specific contexts of use in daily life. A total of 93 studies were identified, describing 29 different IDS that are summarized and classified according to a four-level classification scheme. The predominant user input signal associated with the described IDS was electromyography (35.6%), followed by manual triggers such as buttons, touchscreens or joysticks (16.7%), as well as isometric force generated by residual movement in upper-limb segments (15.1%). We identify and discuss the strengths and weaknesses of IDS with respect to specific contexts of use and highlight a trade-off between performance and complexity in selecting an optimal IDS. Investigating evaluation practices to study the usability of IDS, the included studies revealed that, primarily, objective and quantitative usability attributes related to effectiveness or efficiency were assessed. Further, it underlined the lack of a systematic way to determine whether the usability of an IDS is sufficiently high to be appropriate for use in daily life applications. This work highlights the importance of a user- and application-specific selection and evaluation of non-invasive IDS for ULO. For technology developers in the field, it further provides recommendations on the selection process of IDS as well as to the design of corresponding evaluation protocols.

An analysis of usability evaluation practices and contexts of use in wearable robotics

BACKGROUND

User-centered design approaches have gained attention over the past decade, aiming to tackle the technology acceptance issues of wearable robotic devices to assist, support or augment human capabilities. While there is a consensus that usability is key to user-centered design, dedicated usability evaluation studies are scarce and clear evaluation guidelines are missing. However, the careful consideration and integration of user needs appears to be essential to successfully develop an effective, efficient, and satisfactory human-robot interaction. It is primarily the responsibility of the developer, to ensure that this users involvement takes place throughout the design process.

METHODS

Through an online survey for developers of wearable robotics, we wanted to understand how the design and evaluation in actual daily practice compares to what is reported in literature. With a total of 31 questions, we analyzed the most common wearable robotic device applications and their technology maturity, and how these influence usability evaluation practices.

RESULTS

A total of 158 responses from a heterogeneous population were collected and analyzed. The dataset representing contexts of use for augmentation (16.5%), assistance (38.0%), therapy (39.8%), as well as few other specific applications (5.7%), allowed for an insightful analysis of the influence of technology maturity on user involvement and usability evaluation. We identified functionality, ease of use, and performance as the most evaluated usability attributes and could specify which measures are used to assess them. Also, we could underline the frequent use of qualitative measures alongside the expected high prevalence of performance-metrics. In conclusion of the analysis, we derived evaluation recommendations to foster user-centered design and usability evaluation.

CONCLUSION

This analysis might serve as state-of-the-art comparison and recommendation for usability studies in wearable robotics. We believe that by motivating for more balanced, comparable and user-oriented evaluation practices, we may support the wearable robotics field in tackling the technology acceptance limitations.

The iHand clinical trial protocol: multi-center uncontrolled intervention study to examine the therapeutic effect of a soft-robotic glove as assistive device to support people with impaired hand strength during activities of daily living (Preprint)

Background

Decline of hand function, especially reduced hand strength, is a common problem that can be caused by many disorders and results in difficulties performing activities of daily living. A wearable soft robotic glove may be a solution, enabling use of the affected arm and hand repeatedly during functional daily activities and providing intensive and task-specific training simultaneously with assistance of hand function.

Objective

We aim to investigate the therapeutic effect of an assistive soft robotic glove (Carbonhand).

Methods

This multicenter uncontrolled intervention study consists of 3 preassessments (T0, T1, and T2), a postassessment (T3), and a follow-up assessment (T4). Participants are patients who experience hand function limitations. For the intervention, participants will use the glove during activities of daily living at home for 6 weeks, with a recommended use of at least 180 minutes per week. The primary outcome measure is handgrip strength, and secondary outcome measures are related to functional arm and hand abilities, amount of glove use, and quality of life.

Results

The first participant was included on June 25, 2019. Currently, the study has been extended due to the COVID-19 pandemic; data collection and analysis are expected to be completed in 2022.

Conclusions

The Carbonhand system is a wearable assistive device, allowing performance of functional activities to be enhanced directly during functional daily activities. At the same time, active movement of the user is encouraged as much as possible, which has potential to provide highly intensive and task-specific training. As such, it is one of the first assistive devices to incorporate assist-as-needed principles. This is the first powered clinical trial that investigates the unique application of an assistive grip-supporting soft robotic glove outside of clinical settings with the aim to have a therapeutic effect.

Trial Registration

Netherlands Trial Register NTR NL7561; https://www.trialregister.nl/trial/7561

International Registered Report Identifier (IRRID)

DERR1-10.2196/34200

A scoping review of design requirements for a home-based upper limb rehabilitation robot for stroke

BACKGROUND

Home-based robotic therapy is a trend of post-stroke upper limb rehabilitation. Although home-based upper limb rehabilitation robots have been developed over several decades, no design specification has been published.

OBJECTIVES

To identify and synthesize design requirements considering user and technology needs for a home-based upper limb rehabilitation robot through a scoping review.

METHOD

Studies published between 1 January 2000 and 10 June 2020 in Scopus, Web of Science and PubMed database regarding design requirements for upper limb rehabilitation robots from of stroke survivors or therapists were identified and analyzed. We use 'requirement' as something that is needed or wanted. Two physiotherapists ranked the requirements identified from literature review.

RESULTS

Nine studies were selected for review. They identified 42 requirements regarding functionality (n = 11, 26.2% of total requirements), usability (n = 16, 38.0% of total requirements), software (n = 14, 33.3% of total requirements) and safety (n = 1, 2.4% of total requirements). The main implementation barriers with respect to adherence and monitoring were space, operation, and cost.

CONCLUSION

This is the first research to summarize the design requirements for home-based upper limb rehabilitation robots for stroke survivors. The need for a safe, comfortable, easy to use device which can be individualized and promote specific movements and tasks emerged. The result of this paper captures the design requirements that can be used in future for the development of a design specification. It provides designers and researchers guidance about the real-world needs for home-based upper limb rehabilitation robots for stroke.

What Factors Influence Clinicians' Use of Technology in Neurorehabilitation? A Multisite Qualitative Study

OBJECTIVE

Technology is being increasingly used for physical assessment and interventions in health care settings. However, clinical adoption is relatively slow, and the factors affecting use remain underexplored. This study aimed to investigate factors influencing technology use by clinicians working in neurorehabilitation.

METHODS

In this qualitative study, 9 physical therapists and 9 occupational therapists (N = 18) were recruited from urban and regional locations in Australia and in Singapore. Three 60-minute focus groups were conducted via video conferencing. Each group comprised 3 physical therapists and 3 occupational therapists working across different neurorehabilitation settings. Participants were asked to discuss which technologies they used in their workplace for physical assessment and treatment and barriers, motivators, and future desires for technology use. Transcripts were analyzed independently using an inductive approach to generate codes and themes.

RESULTS

Our results comprised 3 themes and 7 categories. These were encompassed by a single overarching theme, namely "Technology use is influenced by the benefits and challenges of the technology itself, users, and organizational context." Themes showed that technology should promote effective interventions, is preferred if easy to use, and should be dependable. Furthermore, clinical reasoning is important, and users have varying levels of receptivity and confidence in technology use. Also, organizational resources are required, along with supportive cultures and processes, to facilitate technology use.

CONCLUSIONS

The themes identified multiple and interlinking factors influencing clinicians' use of technology in neurorehabilitation settings. Clinicians often consider context-specific benefits and challenges when deciding whether to use technology. Although our study found that clinicians generally perceived technology as having a beneficial role in improving health outcomes, there were several challenges raised. Therefore, the characteristics of the technology itself, individual users, and organizational context should be considered.

IMPACT

These findings will guide successful technology implementation and future developments.

Towards a Platform for Robot-Assisted Minimally-Supervised Therapy of Hand Function: Design and Pilot Usability Evaluation

Background

Robot-assisted therapy can increase therapy dose after stroke, which is often considered insufficient in clinical practice and after discharge, especially with respect to hand function. Thus far, there has been a focus on rather complex systems that require therapist supervision. To better exploit the potential of robot-assisted therapy, we propose a platform designed for minimal therapist supervision, and present the preliminary evaluation of its immediate usability, one of the main and frequently neglected challenges for real-world application. Such an approach could help increase therapy dose by allowing the training of multiple patients in parallel by a single therapist, as well as independent training in the clinic or at home.

Methods

We implemented design changes on a hand rehabilitation robot, considering aspects relevant to enabling minimally-supervised therapy, such as new physical/graphical user interfaces and two functional therapy exercises to train hand motor coordination, somatosensation and memory. Ten participants with chronic stroke assessed the usability of the platform and reported the perceived workload during a single therapy session with minimal supervision. The ability to independently use the platform was evaluated with a checklist.

Results

Participants were able to independently perform the therapy session after a short familiarization period, requiring assistance in only 13.46 (7.69–19.23)% of the tasks. They assigned good-to-excellent scores on the System Usability Scale to the user-interface and the exercises [85.00 (75.63–86.88) and 73.75 (63.13–83.75) out of 100, respectively]. Nine participants stated that they would use the platform frequently. Perceived workloads lay within desired workload bands. Object grasping with simultaneous control of forearm pronosupination and stiffness discrimination were identified as the most difficult tasks.

Discussion

Our findings demonstrate that a robot-assisted therapy device can be rendered safely and intuitively usable upon first exposure with minimal supervision through compliance with usability and perceived workload requirements. The preliminary usability evaluation identified usability challenges that should be solved to allow real-world minimally-supervised use. Such a platform could complement conventional therapy, allowing to provide increased dose with the available resources, and establish a continuum of care that progressively increases therapy lead of the patient from the clinic to the home.

A Pilot Study of the Psychosocial Impact of Low-Cost Assistive Technology for Sexual Functioning in People with Acquired Brain Injury

People with acquired brain injury (ABI) face limitations when performing activities of daily living, including sexuality. Despite the common use among this group of assistive technology to compensate for or neutralize the limitations deriving from their condition, there is very little literature on outcome measures in assistive technology for sexual functioning. The aim of this study was to explore the psychosocial impact of the use of low-cost assistive technology in people with ABI. The sample was made up of 18 users: 15 men and 3 women diagnosed with ABI. The PLISSIT model was used, as well as the Psychosocial Impact of Assistive Device Scale-PIADS as an assessment tool. Three types of low-cost assistive technology were developed: seat cushions, bed equipment, and back supports. All three types of AT obtained positive scores on the PIADS total scale and its three subscales: competence, adaptability, and self-esteem. Although the results of this study are positive, more research into outcome measures for products to improve sexual functioning in people with ABI is required.

Repetitions, duration and intensity of upper limb practice following the implementation of robot assisted therapy with sub-acute stroke survivors: an observational study

BACKGROUND

Robot assisted upper limb (UL) therapy has been identified as an intervention with the potential to help improve the amount of practice performed by stroke survivors.

OBJECTIVES

This study aimed to measure the amount of UL practice (i.e., repetitions, duration, intensity) performed by subacute stroke survivors, in particular those with severe UL impairment, pre and post implementation of robot assisted upper limb therapy (RT-UL) into an inpatient rehabilitation setting.

METHODS

Two observational study phases (pre-RT-UL and post-RT-UL) were undertaken of occupational therapy and physiotherapy sessions performed by subacute stroke survivors. Upper limb tasks observed and recorded in therapy were classified as either impairment-related therapy or activity-related.

RESULTS

In the pre-RT-UL observational phase, 7 subacute stroke survivors were observed across 11 days involving 25 therapy sessions. Post-RT-UL, 12 subacute stroke survivors were observed across 12 days involving 29 therapy sessions. There were no significant differences in characteristics of patients observed in each phase (p > .05). The mean difference (95% CI) between pre and post RT-UL for repetitions (reps) (569 (1 to 1136) and intensity (7 (4-11)) reps/min of practice increased for all patients, including those with severe UL impairment (337 (37-638)) reps and 8 (2-14) reps/minute, with the duration of therapy unchanged.

CONCLUSIONS

This is the first study to have observed an increase in UL practice with the inclusion of RT-UL as part of routine clinical practice. This increase in practice is considered to be due to RT-UL providing highly supportive and expeditious semi-supervised practice. Notably, RT-UL was able to be implemented within the existing organisational structures with only basic training of therapy staff.IMPLICATIONS FOR REHABILITATIONRobotics presents as a viable intervention to increase the amount and intensity of upper limb practice performed by stroke survivors in routine clinical practiceRobotics were able to be implemented within the existing organisational structures with only basic training of therapy staff.

Perspectives on the prospective development of stroke-specific lower extremity wearable monitoring technology: a qualitative focus group study with physical therapists and individuals with stroke

BACKGROUND

Wearable activity monitors that track step count can increase the wearer's physical activity and motivation but are infrequently designed for the slower gait speed and compensatory patterns after stroke. New and available technology may allow for the design of stroke-specific wearable monitoring devices, capable of detecting more than just step counts, which may enhance how rehabilitation is delivered. The objective of this study was to identify important considerations in the development of stroke-specific lower extremity wearable monitoring technology for rehabilitation, from the perspective of physical therapists and individuals with stroke.

METHODS

A qualitative research design with focus groups was used to collect data. Five focus groups were conducted, audio recorded, and transcribed verbatim. Data were analyzed using content analysis to generate overarching categories representing the stakeholder considerations for the development of stroke-specific wearable monitor technology for the lower extremity.

RESULTS

A total of 17 physical therapists took part in four focus group discussions and three individuals with stroke participated in the fifth focus group. Our analysis identified four main categories for consideration: 1) 'Variability' described the heterogeneity of patient presentation, therapy approaches, and therapeutic goals that are taken into account for stroke rehabilitation; 2) 'Context of use' described the different settings and purposes for which stakeholders could foresee employing stroke-specific wearable technology; 3) 'Crucial design features' identified the measures, functions, and device characteristics that should be considered for incorporation into prospective technology to enhance uptake; and 4) 'Barriers to adopting technology' highlighted challenges, including personal attitudes and design flaws, that may limit the integration of current and future wearable monitoring technology into clinical practice.

CONCLUSIONS

The findings from this qualitative study suggest that the development of stroke-specific lower extremity wearable monitoring technology is viewed positively by physical therapists and individuals with stroke. While a single, specific device or function may not accommodate all the variable needs of therapists and their clients, it was agreed that wearable monitoring technology could enhance how physical therapists assess and treat their clients. Future wearable devices should be developed in consideration of the highlighted design features and potential barriers for uptake.

Elicitation of usability-related Requirements for Upper-Limb Rehabilitation Systems

The increasing number of strokes coincides with the need for new effective rehabilitation systems. In this contribution the methods and results of a series of user surveys comprising methods of qualitative research are presented. The goal of these surveys was to elicit requirements health care professionals pose on rehabilitation devices for upper limb training to enable an effective, efficient and satisfying use in a rehabilitation environment. In a two-step process, two different methods - semi-structured interviews and online questionnaire - were combined to collect data from two independent populations. The analysis of the survey showed that the use of a rehabilitation device should be time-effective and bring joy and that the device should be customizable and provide feedback.

Introducing robotic upper limb training into routine clinical practice for stroke survivors: Perceptions of occupational therapists and physiotherapists

INTRODUCTION

Robot-assisted therapy for the upper limb (RT-UL) is an emerging form of intervention for stroke survivors with upper limb deficits. However, there is limited knowledge regarding therapists' perceptions of RT-UL and the factors influencing the implementation of RT-UL into the clinical setting. This is important when considering that therapists in Australia are primarily responsible for the prescription of RT-UL in daily practice. This study aimed to explore occupational therapists' and physiotherapists' perceptions of RT-UL and the perceived barriers and enablers influencing implementation.

METHODS

Two discipline-specific focus groups were conducted involving occupational therapists (n = 6) and physiotherapists (n = 6). Participants were members of the same multidisciplinary team working in an Australian public health rehabilitation facility where RT-UL (i.e. InMotion2) was being introduced for the first time. Focus groups explored therapist perceptions of the new RT-UL as well as perceived barriers and enablers to implementation. Focus groups were recorded, transcribed and deductively analysed using the Theoretical Domains Framework (TDF).

RESULTS

Out of the 14 domains of the TDF, 7 were raised by participants during the focus groups: environmental context and resources, beliefs about consequences, optimism, knowledge, skills, social influences, and social and professional role and identity. Therapists' expressed their optimism towards the introduction of RT-UL but believed successful implementation would be primarily dependent on the availability of clinical leadership, training and a suitable client mix.

CONCLUSION

Therapists perceived that RT-UL would provide opportunity for increased upper limb practice particularly for patients with severe upper limb impairment. To facilitate implementation, support of RT-UL should come from both management and clinical leaders and training include RT-UL efficacy, device functionality and patient suitability. The availability of a single RT-UL device in a workplace may create unique interdisciplinary and logistical challenges.

On the use of symmetrized dot patterns for the visual characterization of speech waveforms and other sampled data

While the spectrogram (and related graphic analyses) have been invaluable in showing the general frequency content of an input signal, sometimes it is difficult for trained and untrained users to see on the spectrogram differences which are perceptible to the ear. In this paper, several demonstrations of a novel representation are presented which, in some cases, can make subtle differences in input signals obvious to the human analyst. The representation, a "symmetrized dot pattern" (SDP), provides a stimulus in which local visual correlations are integrated to form a global percept and can potentially be applied to the detection and characterization of significant features of any sampled data.