Assessing the effectiveness of virtual reality to promote empathy for patients through a mixed-methods study.

OBJECTIVE: To describe the implementation and outcomes of EmpathyVR, an immersive experience using virtual reality (VR) to promote empathy for patients with physical limitations due to chronic diseases. METHODS: First-year student pharmacists participated in a learning experience that incorporated VR and stiff gloves to simulate physical limitations associated with color-blindness and arthritis, respectively. Students completed pre- and post-intervention surveys that included the Kiersma-Chen Empathy Scale and measures of immersion, user enjoyment, perceived usefulness for learning, and adverse effects of the experience. A focus group was also conducted with 6 students to obtain additional feedback on the learning experience. RESULTS: Of the 132 students who were enrolled in the program, 131 completed the assigned tasks; 117 of these agreed to participate in the study, and their data were included in the analyses. There was a significant improvement in empathy scores in the cognitive domain from pre- to post-intervention. Post-intervention survey results also demonstrated a high degree of immersion in the experience, high levels of self-reported enjoyment, and high levels of perceived usefulness of the activity to support learning. There was a low to moderate incidence of minor self-reported adverse effects from the activity. Focus group feedback was also positive. One student stated, "… it really allowed you to think and put yourself in their shoes." CONCLUSION: Implementation of a VR-based learning activity into the first semester of the PharmD curriculum was successful and resulted in improved student empathy scores and a positive learning experience.

Impact of Gravity Compensation on Upper Extremity Movements in Harmony Exoskeleton.

Robots have been used to offset the limb weight through gravity compensation in upper body rehabilitation to delineate the effects of loss of strength and loss of dexterity, which are two common forms of post-stroke impairments. In this paper, we explored the impact of this anti-gravity support on the quality of movement during reaching and coordinated arm movements in a pilot study with two participants with chronic stroke. The subjects donned the Harmony exoskeleton which supported proper shoulder coordination in addition to providing gravity compensation. Participants had previously taken part in seven one-hour sessions with the Harmony exoskeleton, performing six sets of passive-stretching and active exercises. Pre- and post-training sessions included assessments of two separate tasks, planar reaching and a set of six coordinated arm movements, in two conditions, outside of and supported by the exoskeleton. The movements were recorded using an optical motion capture system and analyzed using spectral arc length (SPARC) and straight line deviation to quantify movement smoothness and quality. We observed that gravity compensation resulted in an increased smoothness for the subject with high level of impairment whereas compensation resulted in a reduction in smoothness for the subject with low level of impairment in the reaching task. Both participants demonstrated better coordination of the shoulder-arm joint with gravity compensation. This result motivates further studies into the role of gravity compensation during coordinated movement training and rehabilitation interventions.

Exploring the Capabilities of Harmony for Upper-Limb Stroke Therapy.

Harmony is a bimanual upper-limb exoskeleton designed for post-stroke rehabilitation. It moves the subject's shoulders and arms through their entire ranges of motion while maintaining natural coordination, is capable of force/torque control of each joint, and is equipped with sensors to measure motions and interaction forces. With these capabilities Harmony has the potential to assess motor function and create individualized therapy regimens. As a first step, five stroke survivors underwent rehabilitation sessions practicing multijoint movements with the device. Each participant performed a total of 1130 motions over seven hours of therapy with no adverse effects reported by participants or the attending therapist, supporting the suitability of Harmony for use in a clinical setting. Donning and doffing time averaged 3.5 minutes and decreased with therapist experience. Reported levels of stress, anxiety, and pain indicate that the Harmony safely assisted in the completion of the trained movements and has great potential to motivate and engage patients. We developed a novel methodology for assessing coordination capability and results from the study indicate that Harmony can enable therapists to identify neuromuscular weakness and maladaptive coordination patterns and develop targeted interventions to address these aspects of upper-limb function. The results suggest Harmony's feasibility and show promising improvements, motivating future study to gain statistical support.

Assessing Wrist Movement With Robotic Devices.

Robotic devices have been proposed to meet the rising need for high intensity, long duration, and goal-oriented therapy required to regain motor function after neurological injury. Complementing this application, exoskeletons can augment traditional clinical assessments through precise, repeatable measurements of joint angles and movement quality. These measures assume that exoskeletons are making accurate joint measurements with a negligible effect on movement. For the coupled and coordinated joints of the wrist and hand, the validity of these two assumptions cannot be established by characterizing the device in isolation. To examine these assumptions, we conducted three user-in-the-loop experiments with able-bodied participants. First, we compared robotic measurements to an accepted modality to determine the validity of joint- and trajectory-level measurements. Then, we compared those movements to movements without the device to investigate the effects of device dynamic properties on wrist movement characteristics. Last, we investigated the effect of the device on coordination with a redundant, coordinated pointing task with the wrist and hand. For all experiments, smoothness characteristics were preserved in the robotic kinematic measurement and only marginally impacted by robot dynamics, validating the exoskeletons for use as assessment devices. Stemming from these results, we propose design guidelines for exoskeletal assessment devices.

Maintaining subject engagement during robotic rehabilitation with a minimal assist-as-needed (mAAN) controller.

One challenge of robotic rehabilitation interventions is devising ways to encourage and maintain high levels of subject involvement over long duration therapy sessions. Assist-as-needed controllers have been proposed which modulate robot intervention in movements based on measurements of subject involvement. This paper presents a minimal assist-as-needed controller, which modulates allowable error bounds and robot intervention based on sensorless force measurement accomplished through a nonlinear disturbance observer. While similar algorithms have been validated using healthy subjects, this paper presents a validation of the proposed mAAN control algorithm's ability to encourage user involvement with an impaired individual. User involvement is inferred from muscle activation, measured via surface electromyography (EMG). Experimental validation shows increased EMG muscle activation when using the proposed mAAN algorithm compared to non-adaptive algorithms.

Design and characterization of the OpenWrist: A robotic wrist exoskeleton for coordinated hand-wrist rehabilitation.

Robotic devices have been clinically verified for use in long duration and high intensity rehabilitation needed for motor recovery after neurological injury. Targeted and coordinated hand and wrist therapy, often overlooked in rehabilitation robotics, is required to regain the ability to perform activities of daily living. To this end, a new coupled hand-wrist exoskeleton has been designed. This paper details the design of the wrist module and several human-related considerations made to maximize its potential as a coordinated hand-wrist device. The serial wrist mechanism has been engineered to facilitate donning and doffing for impaired subjects and to insure compatibility with the hand module in virtual and assisted grasping tasks. Several other practical requirements have also been addressed, including device ergonomics, clinician-friendliness, and ambidextrous reconfigurability. The wrist module's capabilities as a rehabilitation device are quantified experimentally in terms of functional workspace and dynamic properties. Specifically, the device possesses favorable performance in terms of range of motion, torque output, friction, and closed-loop position bandwidth when compared with existing devices. The presented wrist module's performance and operational considerations support its use in a wide range of future clinical investigations.

Estimating anatomical wrist joint motion with a robotic exoskeleton.

Robotic exoskeletons can provide the high intensity, long duration targeted therapeutic interventions required for regaining motor function lost as a result of neurological injury. Quantitative measurements by exoskeletons have been proposed as measures of rehabilitative outcomes. Exoskeletons, in contrast to end effector designs, have the potential to provide a direct mapping between human and robot joints. This mapping rests on the assumption that anatomical axes and robot axes are aligned well, and that movement within the exoskeleton is negligible. These assumptions hold well for simple one degree-of-freedom joints, but may not be valid for multi-articular joints with unique musculoskeletal properties such as the wrist. This paper presents an experiment comparing robot joint kinematic measurements from an exoskeleton to anatomical joint angles measured with a motion capture system. Joint-space position measurements and task-space smoothness metrics were compared between the two measurement modalities. The experimental results quantify the error between joint-level position measurements, and show that exoskeleton kinematic measurements preserve smoothness characteristics found in anatomical measures of wrist movements.

System Characterization of MAHI EXO-II: A Robotic Exoskeleton for Upper Extremity Rehabilitation.

This paper presents the performance characterization of the MAHI Exo-II, an upper extremity exoskeleton for stroke and spinal cord injury (SCI) rehabilitation, as a means to validate its clinical implementation and to provide depth to the literature on the performance characteristics of upper extremity exoskeletons. Individuals with disabilities arising from stroke and SCI need rehabilitation of the elbow, forearm, and wrist to restore the ability to independently perform activities of daily living (ADL). Robotic rehabilitation has been proposed to address the need for high intensity, long duration therapy and has shown promising results for upper limb proximal joints. However, upper limb distal joints have historically not benefitted from the same focus. The MAHI Exo-II, designed to address this shortcoming, has undergone a static and dynamic performance characterization, which shows that it exhibits the requisite qualities for a rehabilitation robot and is comparable to other state-of-the-art designs.