Engaging in a home-based exercise program: a mixed-methods approach to identify motivators and barriers for individuals with stroke.

Community-dwelling individuals with chronic stroke used a novel, portable rehabilitation system, mRehab, that uses a smartphone app coupled with 3D printed objects resembling daily use items. The objectives of this study include evaluating participant's approach and nature of engagement with mRehab and identifying factors that influenced the users' engagement with mRehab. An explanatory mixed-method approach was used. In the first phase, 16 participants used mRehab at home for six weeks; six participants were recruited from the first phase for in-depth interviews. Participants were categorized into High, Moderate, and Low Frequency groups based on their frequency of mRehab use. High frequency of use was not related to improved performance on clinical assessments; instead, High Frequency users more commonly initiated performance of new activities after the mRehab program compared to participants with lower frequency of use. Useful activities that are challenging and meaningful to the participants, and availability of objective feedback for self-monitoring were some of the motivators for mRehab use. Difficulty with time management, lack of caregiver availability, and difficulties with the design of the system posed as barriers to mRehab use. Tailoring home programs to the recipients' needs including perceived meaningfulness of the activities is key for long-term rehabilitation.

Participants with mildly-disabling chronic neck pain perform differently during explicit compared to implicit motor learning of a reaching task.

Chronic musculoskeletal (CMSK) pain associated with musculoskeletal disorders like low back pain or neck pain are the leading causes of disability. While CMSK pain has the potential to negatively influence motor learning, there is limited research to understand the impact of CMSK on motor learning. In order to examine differences in motor learning between individuals with and without CMSK we modified a serial reaction time task to assess motor learning of a repetitive reaching task. The paradigm was used to assess both explicit and implicit motor learning. In a cross-sectional study design, seventeen participants with chronic neck pain (CNP) (5 males) and 21 controls (8 males) were recruited. In addition, physical, cognitive, sensorimotor, disability and pain assessments were used to examine differences between individuals with and without CNP. All participants with CNP were categorized as having mild disability. There was no difference in cognitive assessments and minimal differences in physical measures between groups. Examining motor learning, groups with and without CNP demonstrated similar outcomes in both explicit and implicit motor learning. There was one notable performance difference between groups in the reaching task, the group with CNP demonstrated slower reaching movements outward and inward during blocks without explicit information. This may suggest a cautious approach to movement with reduced explicit information. Findings from this study provide insight on motor learning in individuals with mildly-disabling CNP, further research is necessary to examine how instruction can impact peak performance in people with CMSK pain.

Usability, Usefulness, and Acceptance of a Novel, Portable Rehabilitation System (mRehab) Using Smartphone and 3D Printing Technology: Mixed Methods Study.

BACKGROUND: Smart technology use in rehabilitation is growing and can be used remotely to assist clients in self-monitoring their performance. With written home exercise programs being the commonly prescribed form of rehabilitation after discharge, mobile health technology coupled with task-oriented programs can enhance self-management of upper extremity training. In the current study, a rehabilitation system, namely mRehab, was designed that included a smartphone app and 3D-printed household items such as mug, bowl, key, and doorknob embedded with a smartphone. The app interface allowed the user to select rehabilitation activities and receive feedback on the number of activity repetitions completed, time to complete each activity, and quality of movement. OBJECTIVE: This study aimed to assess the usability, perceived usefulness, and acceptance of the mRehab system by individuals with stroke and identify the challenges experienced by them when using the system remotely in a home-based setting. METHODS: A mixed-methods approach was used with 11 individuals with chronic stroke. Following training, individuals with stroke used the mRehab system for 6 weeks at home. Each participant completed surveys and engaged in a semistructured interview. Participants' qualitative reports regarding the usability of mRehab were integrated with their survey reports and quantitative performance data. RESULTS: Of the 11 participants, 10 rated the mRehab system between the 67.5th and 97.5th percentile on the System Usability Scale, indicating their satisfaction with the usability of the system. Participants also provided high ratings of perceived usefulness (mean 5.8, SD 0.9) and perceived ease of use (mean 5.3, SD 1.5) on a 7-point scale based on the Technology Acceptance Model. Common themes reported by participants showed a positive response to mRehab with some suggestions for improvements. Participants reported an interest in activities they perceived to be adequately challenging. Some participants indicated a need for customizing the feedback to be more interpretable. Overall, most participants indicated that they would like to continue using the mRehab system at home. CONCLUSIONS: Assessing usability in the lived environment over a prolonged duration of time is essential to identify the match between the system and users' needs and preferences. While mRehab was well accepted, further customization is desired for a better fit with the end users. TRIAL REGISTRATION: ClinicalTrials.gov NCT04363944; https://clinicaltrials.gov/ct2/show/NCT04363944.

In-Home Rehabilitation Using a Smartphone App Coupled With 3D Printed Functional Objects: Single-Subject Design Study.

BACKGROUND: Stroke is a major cause of long-term disability. While there is potential for improvements long after stroke onset, there is little to support functional recovery across the lifespan. mHealth solutions can help fill this gap. mRehab was designed to guide individuals with stroke through a home program and provide performance feedback. OBJECTIVE: To examine if individuals with chronic stroke can use mRehab at home to improve upper limb mobility. The secondary objective was to examine if changes in limb mobility transferred to standardized clinical assessments. METHODS: mRehab consists of a smartphone coupled with 3D printed household items: mug, bowl, key, and doorknob. The smartphone custom app guides task-oriented activities and measures both time to complete an activity and quality of movement (smoothness/accuracy). It also provides performance-based feedback to aid the user in self-monitoring their performance. Task-oriented activities were categorized as (1) object transportation, (2) prehensile grip with supination/pronation, (3) fractionated finger movement, and (4) walking with object. A total of 18 individuals with stroke enrolled in the single-subject experimental design study consisting of pretesting, a 6-week mRehab home program, and posttesting. Pre- and posttesting included both in-laboratory clinical assessments and in-home mRehab recorded samples of task performance. During the home program, mRehab recorded performance data. A System Usability Scale assessed user's perception of mRehab. RESULTS: A total of 16 participants completed the study and their data are presented in the results. The average days of exercise for each mRehab activity ranged from 15.93 to 21.19 days. This level of adherence was sufficient for improvements in time (t15=2.555, P=.02) and smoothness (t15=3.483, P=.003) in object transportation. Clinical assessments indicated improvements in functional performance (t15=2.675, P=.02) and hand dexterity (t15=2.629, P=.02). Participant's perception of mRehab was positive. CONCLUSIONS: Despite heterogeneity in participants' use of mRehab, there were improvements in upper limb mobility. Smartphone-based portable technology can support home rehabilitation programs in chronic conditions such as stroke. The ability to record performance data from home rehabilitation offers new insights into the impact of home programs on outcomes. TRIAL REGISTRATION: ClinicalTrials.gov NCT04363944; https://clinicaltrials.gov/ct2/show/NCT04363944.

Harnessing smartphone technology and three dimensional printing to create a mobile rehabilitation system, mRehab: assessment of usability and consistency in measurement.

BACKGROUND: Residual sensorimotor deficits are common following stroke. While it has been demonstrated that targeted practice can result in improvements in functional mobility years post stroke, there is little to support rehabilitation across the lifespan. The use of technology in home rehabilitation provides an avenue to better support self-management of recovery across the lifespan. We developed a novel mobile technology, capable of quantifying quality of movement with the purpose of providing feedback to augment rehabilitation and improve functional mobility. This mobile rehabilitation system, mRehab, consists of a smartphone embedded in three dimensional printed items representing functional objects found in the home. mRehab allows individuals with motor deficits to practice activities of daily living (ADLs) and receive feedback on their performance. The aim of this study was to assess the usability and consistency of measurement of the mRehab system. METHODS: To assess usability of the mRehab system, four older adults and four individuals with stroke were recruited to use the system, and complete surveys to discuss their opinions on the user interface of the smartphone app and the design of the 3D printed items. To assess the consistency of measurement by the mRehab system, 12 young adults were recruited and performed mRehab ADLs in three lab sessions within 1 week. Young adults were chosen for their expected high level of consistency in motor performance. RESULTS: Usability ratings from older adults and individuals with stroke led us to modify the design of the 3D printed items and improve the clarity of the mRehab app. The modified mRehab system was assessed for consistency of measurement and six ADLs resulted in coefficient of variation (CV) below 10%. This is a commonly used CV goal for consistency. Two ADLs ranged between 10 and 15% CV. Only two ADLs demonstrated high CV. CONCLUSIONS: mRehab is a client-centered technology designed for home rehabilitation that consistently measures performance. Development of the mRehab system provides a support for individuals working on recovering functional upper limb mobility that they can use across their lifespan.

Reported use of technology in stroke rehabilitation by physical and occupational therapists.

PURPOSE: With the patient care experience being a healthcare priority, it is concerning that patients with stroke reported boredom and a desire for greater fostering of autonomy, when evaluating their rehabilitation experience. Technology has the potential to reduce these shortcomings by engaging patients through entertainment and objective feedback. Providing objective feedback has resulted in improved outcomes and may assist the patient in learning how to self-manage rehabilitation. Our goal was to examine the extent to which physical and occupational therapists use technology in clinical stroke rehabilitation home exercise programs. MATERIALS AND METHODS: Surveys were sent via mail, email and online postings to over 500 therapists, 107 responded. RESULTS: Conventional equipment such as stopwatches are more frequently used compared to newer technology like Wii and Kinect games. Still, less than 25% of therapists' report using a stopwatch five or more times per week. Notably, feedback to patients is based upon objective data less than 50% of the time by most therapists. At the end of clinical rehabilitation, patients typically receive a written home exercise program and non-technological equipment, like theraband and/or theraputty to continue rehabilitation efforts independently. CONCLUSIONS: The use of technology is not pervasive in the continuum of stroke rehabilitation. Implications for Rehabilitation The patient care experience is a priority in healthcare, so when patients report feeling bored and desiring greater fostering of autonomy in stroke rehabilitation, it is troubling. Research examining the use of technology has shown positive results for improving motor performance and engaging patients through entertainment and use of objective feedback. Physical and occupational therapists do not widely use technology in stroke rehabilitation. Therapists should consider using technology in stroke rehabilitation to better meet the needs of the patient.

Understanding User Requirements for the Design of a Home-Based Stroke Rehabilitation System.

Limitations following stroke make it one of the leading causes of disability. The current medical pathway provides intensive care in the acute stages, but rehabilitation services are commonly discontinued after one year. While written home exercise programs are regularly prescribed at the time of discharge, compliancy is an issue. The goal of this study was to inform the design of a home-based portable rehabilitation system based on feedback from individuals with stroke and clinicians. A main component under consideration is the type and format of information feedback provided to the user, as this is hypothesized to support compliance with the rehabilitation program. From a series of focus groups and usability testing, a set of design requirements for the hardware and software were constructed. Essential features mentioned for the feedback interface included: task completion time, quality of movement, a selection of exercises, goal tracking, and a display of historical data.

Older adults demonstrate greater accuracy in joint position matching using self-guided movements.

Greater proprioceptive accuracy has been found with active compared to passive movement. Therapeutic approaches in rehabilitation include varying levels of assistance with arm movements. This assistance may impact proprioceptive acuity. Eighteen older adults participated in a joint repositioning study. The ability to independently reproduce a shoulder flexion angle was investigated when the reference angle was set under the following conditions: (1) the examiner actively assisted participant's motion to the reference angle chosen by the examiner, (2) the participant moved independently, but the examiner provided tactile cueing to stop at the reference angle chosen by the examiner, and (3) the participant independently moved to a self-selected reference angle. Participants were most accurate in the self-guided condition compared to the active assisted or tactile cueing conditions. Both the self-guided and tactilely cued conditions involved active movement, yet accuracy differed. In contrast, there was no difference in accuracy between the active assisted and tactile cueing conditions despite one involving more active movement. The results demonstrate active movement alone does not determine accuracy. External stimuli, either tactile input and/or a reference angle chosen by the examiner may diminish accuracy. This can be clinically relevant as proprioceptive performance has been linked to improved motor performance.

Upper-limb position sense deficits in adults with cerebral palsy.

OBJECTIVE: The aim of this study was to examine proprioceptive performance in adults with hemiplegic cerebral palsy and the possibility that a home-based sensorimotor training program could improve proprioceptive performance. DESIGN: This study is a preintervention/postintervention assessment of 12 adults participating in a home-based program consisting of targeted unilateral and bilateral reaching movements, hand manipulation tasks, tactile discrimination, and stereognosis. It did not specifically include proprioceptive tasks. Training sessions were 45 mins, 5 days per week, for 8 wks. Limb position sense was assessed using three conditions: ipsilateral remembered (same arm used for reference and matching targets), contralateral concurrent (reference arm moved and held at target position while opposite arm matched reference position), and contralateral remembered (reference arm moved to target position and then returned to start position before opposite arm matching position). RESULTS: The participants demonstrated greater absolute and constant error when the more affected arm served as the reference arm, and matching was performed by the less affected arm, particularly in the contralateral remembered condition. After training, the participants demonstrated less absolute error across matching tasks and no change in constant error. CONCLUSIONS: The results suggest an important role for the reference arm in bilateral position matching tasks and the potential for improved proprioceptive performance after training in movement and unrelated sensory tasks.

Home-based telerehabilitation shows improved upper limb function in adults with chronic stroke: a pilot study.

OBJECTIVE: This pilot study investigates the use of telerehabilitation to improve upper limb performance in chronic stages of stroke recovery. DESIGN: Intervention study with pre/post/one month follow-up tests. METHODS: Seven adults with chronic stroke participated in the study. Tests consisted of lab-based clinical and kinematic assessments. Participants completed the Upper Limb Training and Assessment (ULTrA) program at home. Training was 5 days/week, 60 min/day for 6 weeks with intermittent supervision of participants. RESULTS: Participants showed improvements in the training program tasks as well as clinical and kinematic assessments. Results also suggest there may be auxiliary benefits in cognitive function. CONCLUSIONS: A home-based telerehabilitation program is a viable approach to provide rehabilitation in chronic stages of stroke.

Age differences in spatial working memory contributions to visuomotor adaptation and transfer.

Throughout our life span we encounter challenges that require us to adapt to the demands of our changing environment; this entails learning new skills. Two primary components of motor skill learning are motor acquisition, the initial process of learning the skill, and motor transfer, when learning a new skill is benefitted by the overlap with a previously learned one. Older adults typically exhibit declines in motor acquisition compared to young adults, but remarkably, do not demonstrate deficits in motor transfer [10]. Our recent work demonstrates that a failure to engage spatial working memory (SWM) is associated with skill learning deficits in older adults [16]. Here, we investigate the role that SWM plays in both motor learning and transfer in young and older adults. Both age groups exhibited performance savings, or positive transfer, at transfer of learning for some performance variables. Measures of spatial working memory performance and reaction time correlated with both motor learning and transfer for young adults. Young adults recruited overlapping brain regions in prefrontal, premotor, parietal and occipital cortex for performance of a SWM and a visuomotor adaptation task, most notably during motor learning, replicating our prior findings [12]. Neural overlap between the SWM task and visuomotor adaptation for the older adults was limited to parietal cortex, with minimal changes from motor learning to transfer. Combined, these results suggest that age differences in engagement of cognitive strategies have a differential impact on motor learning and transfer.

Age differences in callosal contributions to cognitive processes.

In many cases bilateral cortical activation in older adults has been associated with better task performance, suggesting that a greater reliance on interhemispheric interactions aids performance. Interhemispheric communication is primarily mediated via the corpus callosum (CC), however with advancing age the anterior half of the CC undergoes significant atrophy. Here we determine whether there are age differences in the relationship between cross-sectional area of the CC and performance on cognitive tests of psychomotor processing speed and working memory. We found that older adults had significantly smaller callosal area in the anterior and mid-body of the CC than young adults. Furthermore, older adults with larger size in these callosal areas performed better on assessments of working memory and processing speed. Our results indicate that older adults with larger size of the anterior half of the CC exhibit better cognitive function, although their performance was still poorer than young adults with similar CC size. Thus, while the capability for interhemispheric interactions, as inferred from callosal size, may provide performance benefits for older adults, this capacity alone does not assure protection from general performance decline.

Influence of task on interlimb coordination in adults with cerebral palsy.

OBJECTIVE: To examine movement time and kinematic properties of unilateral and bilateral reaching movements in adults with cerebral palsy (CP), focusing on how different types of bilateral movements, simultaneous or sequential, may influence interlimb coordination. DESIGN: Quantitative study using between-group repeated-measures analyses. SETTING: Motor control laboratory at a research university. PARTICIPANTS: Adults with hemiplegic CP (n=11; mean age ± SD, 33±10y; 4 men) and age-matched controls (mean age ± SD, 32±9y; 4 men). INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Movement time (MT), maximum deviation from a straight trajectory to the target, and peak speed. RESULTS: Although adults with hemiplegic CP showed strong unilateral deficits, bilateral simultaneous reaching movements were temporally and spatially coupled. Movement of the less affected arm slowed to match the movement of the more affected arm. In contrast, bilateral sequential movements improved MTs of the less affected and more affected arms. CONCLUSIONS: Bilateral sequential movements were conducive to faster MT compared with unilateral or bilateral simultaneous movements. Training that includes bilateral sequential movements may be beneficial to adults with hemiplegic CP. Upper-limb movements are coordinated in a variety of ways to perform routine bilateral tasks. Some bilateral tasks, such as stacking boxes, require more symmetric movements of the upper limbs. Other bilateral tasks, such as opening the refrigerator with 1 hand while placing an item on the shelf with the other hand, emphasize coordinated sequential action between upper limbs. Despite the prevalence of integrative upper-limb use, the control of different forms of bilateral movement is not well understood. A more comprehensive knowledge of upper-limb bilateral movements may hold important implications for developing more effective upper-limb movement therapies.

Functional implications of age differences in motor system connectivity.

Older adults show less lateralized task-related brain activity than young adults. One potential mechanism of this increased activation is that age-related degeneration of the corpus callosum (CC) may alter the balance of inhibition between the two hemispheres. To determine whether age differences in interhemispheric connectivity affect functional brain activity in older adults, we used magnetic resonance imaging (MRI) to assess resting functional connectivity and functional activation during a simple motor task. We found that older adults had smaller CC area compared to young adults. Older adults exhibited greater recruitment of ipsilateral primary motor cortex (M1), which was associated with longer reaction times. Additionally, recruitment of ipsilateral M1 in older adults was correlated with reduced resting interhemispheric connectivity and a larger CC. We suggest that reduced interhemispheric connectivity reflects a loss of the ability to inhibit the non-dominant hemisphere during motor task performance for older adults, which has a negative impact on performance.

The influence of hand dominance on the response to a constraint-induced therapy program following stroke.

BACKGROUND: Following stroke it is common to exhibit deficits in mobility of the upper extremity. Constraint-induced therapy (CIT) is a rehabilitation technique used to promote use of the more affected hand via constraint of the less affected hand. One factor that could impact the outcome following CIT is hand dominance. Years of preferred use of one hand may give individuals with the dominant hand affected by stroke an advantage in improving the mobility of the more affected hand compared to those individuals with the nondominant hand affected by stroke. In addition, the diminished use of the less affected hand during CIT may also create changes. OBJECTIVE: Our goal was to better understand how hand dominance may influence the response to a CIT program both cortically and behaviorally in both the more affected hand and less affected constrained hand. METHODS: A repeated measures design with a double baseline was used to assess changes in clinical tests and functional magnetic resonance imaging (fMRI) in individuals with their dominant or nondominant hand affected by stroke involved in a CIT program. RESULTS: No significant differences were found between groups in their responses to CIT. Overall subjects demonstrated behavioral and cortical changes with the more affected hand and the less affected constrained hand did not significantly change. CONCLUSION: CIT promotes improvement of the more affected hand particularly on complex tests without decrements to the less affected constrained hand. Cortically, statistically significant changes in activation were noted after the intervention for the more affected hand; no changes were noted with the less affected constrained hand.

Attentional disengagement dysfunction following mTBI assessed with the gap saccade task.

Concussion, or mild traumatic brain injury (mTBI), leads to a number of cognitive, attentional, and sensorimotor deficits that can last a surprisingly long time after the initial injury. We have previously shown that the ability to orient visuospatial attention is deficient in participants with mTBI within 2 days of their injury, but then recovers to normal levels within a week. Orienting attention requires disengagement from the point of fixation, movement of attention to the location of interest, and re-engagement at that location. Deficits in any or all of these processes could lead to the difficulties with orienting attention that we have observed in mTBI. To address this issue, we tested participants with mTBI using a gap saccade task. Because this task manipulates the temporal gap between the offset of the fixation target and the appearance of the peripheral saccade target, it isolates the contribution of the disengagement process to saccadic reaction time. We found that participants with mTBI had significantly longer saccadic reaction times than controls when the temporal gap was short but not when it was long. This gap-dependent difference in saccadic reaction time was present within 2 days of the injury and resolved within 1 week. This pattern of results suggests that as the contribution of the disengagement process is reduced, so too is the extent of the reaction time deficit in the participants with mTBI. Taken together, this is consistent with the idea that the deficits in orienting visuospatial attention in participants with mTBI are fully accounted for by difficulties with the initial disengagement process.

Cancelling planned actions following mild traumatic brain injury.

Mild traumatic brain injury (mTBI) leads to a variety of attentional, cognitive, and sensorimotor deficits. An important aspect of behavior that intersects each of these functions is the ability to cancel a planned action. Thus, the purpose of this study was to determine the effects of mTBI on the ability to perform a countermanding saccade task. In this task, participants were asked to generate a saccade to a target appearing in peripheral vision, but to inhibit saccade execution if an auditory stop signal was presented. The delay between the appearance of the peripheral target and the presentation of the auditory stop signal was varied between 0 and 125ms. We found that the change in the probability of cancelling the saccade as a function of this delay was no different between participants with mTBI tested within 2 days of their injury and matched controls. However, saccadic reaction times and the stop signal reaction time were unexpectedly faster in the participants with mTBI and, furthermore, they inaccurately inhibited saccades during 15% of the trials with no stop signal. Taken together, this data suggests that the ability to cancel planned actions is subtly yet adversely affected by mTBI.

The influence of mild traumatic brain injury on the temporal distribution of attention.

The purpose of this study was to examine whether the temporal dynamics of attention was deficient in participants who have recently experienced mild traumatic brain injury (mTBI). For this purpose the rapid serial visual presentation (RSVP) task was used and the performance of participants with mTBI was compared to that of controls matched for age, gender, education, and activity type. In the RSVP task a stream of rapidly presented letters is displayed with target and probe letters separated by varying durations. The participant is required to identify the target letter and determine whether the probe letter was present or not. Previous research has shown that healthy participants display an attentional blink: they fail to detect the probe letter when it appears within approximately 500 ms of the target letter. We found that participants with mTBI had a normal attentional blink-it was neither greater in magnitude nor longer in duration than that displayed by the control participants. However, the participants with mTBI did show evidence of attentional competition-making more errors in identifying the target letter when the probe letter was presented-that was not present in the control participants. Taken together, these results suggest that the temporal constraints of attention are subtly but systematically affected by mTBI.