A qualitative study on user acceptance of a home-based stroke telerehabilitation system

Purpose: This abstract reports a qualitative study on a home-based stroke telerehabilitation system. The telerehabilitation system delivers treatment sessions in the form of daily guided rehabilitation games, exercises, and stroke education at the patient’s home. Therapists examine patients then establish regular videoconferences with them via the system to discuss their progress, provide feedback, and adjust treatment. The aims of this study were to investigate patients’ general impressions about the benefits of and barriers to using the telerehabilitation system at home. Methods: We used a qualitative study design that involved in-depth semi-structured interviews with 10 participants who had completed a 6-week intervention using the telerehabilitation system. Thematic analysis was conducted using the grounded theory approach. Results: Participants mostly reported positive experiences with the telerehabilitation system. Benefits included observed improvements in limb functions and provision of an outlet for mental tension and anxiety. They mainly valued the following four merits of the system: engaging game experience, flexibility in time and location in using the system, having the therapists accountable, and having less burden on caregivers. In particular, all participants rated highly their experience using the videoconference capability, which provided a channel for therapists to observe, correct, and provide feedback and encouragement to patients. Most patients expressed that they established a personal connection with the therapist through use of the telerehabilitation system. By doing so, they felt less isolated and more positive and connected. Finally, communicating with therapists three times a week also held patients accountable for completing the exercises. Barriers to system use were all logistics-related, such as the lack of physical space at home, which impeded effective use, and poor internet connection at home. Conclusions: The telerehabilitation system studied provides patients with home-based access to games, exercises, education, and therapists. Based on participants’ qualitative feedback, it is a promising tool to deliver stroke rehabilitation therapies effectively and remotely to patients at home.

As a promising alternative to hospital-based manual therapy, robot-assisted tele-rehabilitation therapy has shown significant benefits in reducing the therapist's workload and accelerating the patient's recovery process. However, existing telerobotic systems for rehabilitation face barriers to implementing appropriate therapy treatment due to the lack of effective therapist-patient interactive capabilities. In this paper, we develop a home-based tele-rehabilitation system that implements two alternative training methods, including a haptic-enabled guided training that allows the therapist to adjust the intensity of therapeutic movements provided by the rehabilitation device and a surface electromyography (sEMG)-based supervised training that explores remote assessment of the patient's kinesthetic awareness. Preliminary experiments were conducted to demonstrate the feasibility of the proposed alternative training methods and evaluate the functionality of the developed tele-rehabilitation system. Results showed that the proposed tele-rehabilitation system enabled therapist-in-the-loop to dynamically adjust the rehabilitation intensity and provided more interactivity in therapist-patient remote interaction.

Background. Although rehabilitation therapy is commonly provided after stroke, many patients do not derive maximal benefit because of access, cost, and compliance. A telerehabilitation-based program may overcome these barriers. We designed, then evaluated a home-based telerehabilitation system in patients with chronic hemiparetic stroke. Methods. Patients were 3 to 24 months poststroke with stable arm motor deficits. Each received 28 days of telerehabilitation using a system delivered to their home. Each day consisted of 1 structured hour focused on individualized exercises and games, stroke education, and an hour of free play. Results. Enrollees (n = 12) had baseline Fugl-Meyer (FM) scores of 39 ± 12 (mean ± SD). Compliance was excellent: participants engaged in therapy on 329/336 (97.9%) assigned days. Arm repetitions across the 28 days averaged 24,607 ± 9934 per participant. Arm motor status showed significant gains (FM change 4.8 ± 3.8 points, P = .0015), with half of the participants exceeding the minimal clinically important difference. Although scores on tests of computer literacy declined with age (r = −0.92; P < .0001), neither the motor gains nor the amount of system use varied with computer literacy. Daily stroke education via the telerehabilitation system was associated with a 39% increase in stroke prevention knowledge (P = .0007). Depression scores obtained in person correlated with scores obtained via the telerehabilitation system 16 days later (r = 0.88; P = .0001). In-person blood pressure values closely matched those obtained via this system (r = 0.99; P < .0001). Conclusions. This home-based system was effective in providing telerehabilitation, education, and secondary stroke prevention to participants. Use of a computer-based interface offers many opportunities to monitor and improve the health of patients after stroke.

Evidence suggests that greater duration and intensity of rehabilitation therapy improves outcomes for patients with stroke. Delivery of care is often limited, however, e.g., due to systems of care delivery, cost, rural location, or difficulty travelling. The current study addressed this unmet need by examining the feasibility of a home-based telerehabilitation system. Entry criteria included age &gt;18 yrs, 12-26 wk post stroke, and arm motor deficits (Fugl-Meyer (FM) score 22-55) that were stable. Each subject received 28 d of daily home-based telerehabilitation using a fixed system that we delivered/assembled. Each day consisted of 1 structured hour (testing, BP check, individualized exercises and games, and stroke prevention education) plus up to 1 hour of free play on dozens of games. Each week, subjects had a 1 videoconference with a licensed therapist and 1 with a research assistant; subjects could also phone the lab for technical support if needed. Enrollees were 54±17 yr (mean±SD), 6M/6F, with baseline FM=39±12 (range 23-55). Compliance was excellent, with subjects engaging in therapy 329 of 336 (97.9%) assigned days. Arm motor status improved (FM change 4.8±3.8 points from baseline to 1 mo post-therapy, p=0.0015). Although scores on tests of computer literacy declined with age (r = -0.90 to -0.92, p&lt;0.0001), as expected, the arm motor gains derived from use of this system did not vary with age. The stroke education module was associated with significant gains in stroke prevention knowledge. BP was recorded by the patient, and results automatically transmitted to lab, on 97.9% of assigned days. Therapist videoconferences detected PHQ-2 scores consistent with depression in 3/12 patients. Therapists were able to review patient performances and upload revised therapy settings to the patient’s home system without difficulty at any time of day. Results of this pilot study support the utility of a home-based system to effectively deliver telerehabilitation, improve patient education, screen for complications of stroke, and as well as to provide a means for patient interaction with medical personnel. The use of a computer-based interface offers many opportunities to monitor and improve the health of patients after stroke.

BackgroundThe use of wearable technology offers a promising home-based self-directed option for upper limb training. Although product usability is a crucial aspect of users’ acceptance of a wearable device, usability studies in wearable devices are rare, with most studies focusing primarily on clinical validity.ObjectiveThis study aimed to explore the usability of a wristwatch device called “Smart reminder” for home-based upper limb telerehabilitation for persons with stroke.MethodsEleven stroke participants used the proposed wristwatch for at least two weeks and underwent a home-based telerehabilitation program. A mixed-methods design was used to explore the usability of the wristwatch. Quantitative data were collected through the System Usability Scale (SUS) questionnaire, and the participants’ rate of therapy compliance (gathered from the device) was reported descriptively. In addition, qualitative data were collected through semi-structured interviews with the participants and were analyzed using thematic analysis.ResultsThe results demonstrated that the usability of the proposed wristwatch and telerehabilitation system was rated highly by the participants, with a high SUS mean score of 84.3 (12.3) and high therapy compliance rate (mean = 91%). Qualitatively, all participants reported positive experiences with the wristwatch and indicated keenness to use it again. Participants reported physical improvements and felt motivated to exercise after using the wristwatch. They found the device easy and convenient and appreciated the remote monitoring function. Meanwhile, they highlighted critical considerations for the design of the device and program, including technical support, a wearable design of the device, graded exercise content according to ability, and flexibility in exercise schedules. Finally, they suggested that an interim review with the therapist on their progress might help them continue using the wristwatch.ConclusionsThis study's results supported the proposed wearable device's usability and showed strong acceptance by the participants for using it as a home-based upper limb telerehabilitation intervention.

Tele-rehabilitation has flourished in recent years. The aim of this study was to develop a remote rehabilitation program adapted to regional needs. Due to the high density of medical resources, people in Taiwan can easily and frequently enter has medical institutions. However, this has caused crowds in medical institutions and has affected the quality of rehabilitation for stroke survivors. Upper extremity impairments after a stroke result in functional limitations that impinge on the daily lives of stroke survivors. Task-oriented training (TOT) has been shown to improve recovery after a stroke. In this study, a tele-rehabilitation system, called TOT@home, was designed to enhance the quality of rehabilitation in clinics and facilitate home-based TOT training with remote monitoring.

Many patients receive suboptimal rehabilitation therapy doses after stroke owing to limited access to therapists and difficulty with transportation, and their knowledge about stroke is often limited. Telehealth can potentially address these issues. To determine whether treatment targeting arm movement delivered via a home-based telerehabilitation (TR) system has comparable efficacy with dose-matched, intensity-matched therapy delivered in a traditional in-clinic (IC) setting, and to examine whether this system has comparable efficacy for providing stroke education. In this randomized, assessor-blinded, noninferiority trial across 11 US sites, 124 patients who had experienced stroke 4 to 36 weeks prior and had arm motor deficits (Fugl-Meyer [FM] score, 22-56 of 66) were enrolled between September 18, 2015, and December 28, 2017, to receive telerehabilitation therapy in the home (TR group) or therapy at an outpatient rehabilitation therapy clinic (IC group). Primary efficacy analysis used the intent-to-treat population. Participants received 36 sessions (70 minutes each) of arm motor therapy plus stroke education, with therapy intensity, duration, and frequency matched across groups. Change in FM score from baseline to 4 weeks after end of therapy and change in stroke knowledge from baseline to end of therapy. A total of 124 participants (34 women and 90 men) had a mean (SD) age of 61 (14) years, a mean (SD) baseline FM score of 43 (8) points, and were enrolled a mean (SD) of 18.7 (8.9) weeks after experiencing a stroke. Among those treated, patients in the IC group were adherent to 33.6 of the 36 therapy sessions (93.3%) and patients in the TR group were adherent to 35.4 of the 36 assigned therapy sessions (98.3%). Patients in the IC group had a mean (SD) FM score change of 8.36 (7.04) points from baseline to 30 days after therapy (P < .001), while those in the TR group had a mean (SD) change of 7.86 (6.68) points (P < .001). The covariate-adjusted mean FM score change was 0.06 (95% CI, -2.14 to 2.26) points higher in the TR group (P = .96). The noninferiority margin was 2.47 and fell outside the 95% CI, indicating that TR is not inferior to IC therapy. Motor gains remained significant when patients enrolled early (<90 days) or late (≥90 days) after stroke were examined separately. Activity-based training produced substantial gains in arm motor function regardless of whether it was provided via home-based telerehabilitation or traditional in-clinic rehabilitation. The findings of this study suggest that telerehabilitation has the potential to substantially increase access to rehabilitation therapy on a large scale. ClinicalTrials.gov identifier: NCT02360488.

Recent studies demonstrated that exercise interventions in significantly disabled patients with multiple sclerosis (PwMS) resulted in endurance and strength improvement and reduction of fatigue and spasticity. However engagement in long-term exercise training is limited in these patients due to multiple barriers including mobility, access to an exercise facility, and cost. It is unclear if PwMS with significant mobility disability are willing and able to engage in home-based telerehabilitation. The goal of this study was to assess level of acceptance and ability of these patients to carry out exercises using the telerehabilitation system without supervision. Ten PwMS with significant mobility disability were instructed how to use the telerehabilitation system and were then asked to use it independently according to predefined set of tasks. Feasibility was assessed by ability of study participants to successfully follow exercise tasks provided by a touch screen tablet. Telerehabilitation acceptance was measured by an attitudinal survey. Participant characteristics were: age=53±11, PDDS=5.3±2.4, years with MS=16±9. Average time required to train the patients to use the telerehabilitation system at home for flexibility and resistance exercises was 11±3 minutes and for active arm/leg biking: 3±1 minutes. All patients were able to successfully complete flexibility and resistance exercises and navigate the interface for arm biking exercise. Heart rate readings were affected by noise in some subjects. Active leg cycling was completed by 50% of patients, another half was unable to use it due to severe lower limb mobility impairment. Passive leg cycling supported by a splinting device was successfully operated by 100%. Overall, high acceptance and usability of the system in PwMS with severe mobility disability was demonstrated. This approach has a potential in supporting a comprehensive exercise delivery model in PwMS with significant mobility disability which will support individualized prescription of tailored endurance, strength, and therapeutic physiotherapy exercises.

SummaryIt is well known that the sense of presence in a tele-robot system for both home-based tele-rehabilitation and rescue operations is enhanced by haptic feedback. Beyond several advantages, in the presence of communication delay haptic feedback can lead to an unstable teleoperation system. During the last decades, several control techniques have been proposed to ensure a good trade-off between transparency and stability in bilateral teleoperation systems under time delays. These proposed control approaches have been extensively tested with teleoperation systems based on identical master and slave robots having few degrees of freedom (DoF). However, a small number of DoFs cannot ensure both an effective restoration of the multi-joint coordination in tele-rehabilitation and an adequate dexterity during manipulation tasks in rescue scenario. Thus, a deep understanding of the applicability of such control techniques on a real bilateral teleoperation setup is needed. In this work, we investigated the behavior of the time-domain passivity approach (TDPA) applied on an asymmetrical teleoperator system composed by a 5-DoFs impedance designed upper-limb exoskeleton and a 4-DoFs admittance designed anthropomorphic robot. The conceived teleoperation architecture is based on a velocity–force (measured) architecture with position drift compensation and has been tested with a representative set of tasks under communication delay (80 ms round-trip). The results have shown that the TDPA is suitable for a multi-DoFs asymmetrical setup composed by two isomorphic haptic interfaces characterized by different mechanical features. The stability of the teleoperator has been proved during several (1) high-force contacts against stiff wall that involve more Cartesian axes simultaneously, (2) continuous contacts with a stiff edge tests, (3) heavy-load handling tests while following a predefined path and (4) high-force contacts against stiff wall while handling a load. The found results demonstrated that the TDPA could be used in several teleoperation scenarios like home-based tele-rehabilitation and rescue operations.

Physical therapy has been shown effective in geriatric population in addressing mobility limitation. Telerehabilitation systems may support physical therapy programs at patient homes however such systems were not systematically assessed in seniors. The Home Automated Telemanagement (HAT) system for in-home physical telerehabilitation of seniors with mobility limitations was developed and tested. The HAT rehabilitation system was designed to allow patients with mobility limitations to complete an individualized physical therapy plan prescribed by a physical therapist and to allow for clinicians to monitor and assist with in-home rehabilitation. We conducted a 12-week study to assess the feasibility and patient acceptance of the system. Our results showed that home-based physical telerehabilitation is feasible in seniors with mobility limitations, and it can potentially improve patient functional status significantly. Statistically significant improvement was documented using Berg Balance Scale (change from 36.6 ± 12.1 to 41.7 ± 11.1, p<;0.004), Timed 25-foot Walk (change from 13.5 ± 8.6 to 10.6 ± 4.5, p<;0.04), and 6-minute walk (change from 36.6 ± 12.1 to 41.7 ± 11.1, p<;0.004). The participants of the study demonstrated a very high level of support for the home-based physical telerehabilitation program.

To increase people's access to rehabilitation services, particularly in the context of the COVID-19 pandemic, we need to explore how the delivery of these services can be adapted. This includes the use of home-based rehabilitation and telerehabilitation. Home-based rehabilitation services may become frequently used options in the recovery process of patients, not only as a solution to accessibility barriers, but as a complement to the usual in-person inpatient rehabilitation provision. Telerehabilitation is also becoming more viable as the usability and availability of communication technologies improve. To identify factors that influence the organisation and delivery of in-person home-based rehabilitation and home-based telerehabilitation for people needing rehabilitation. We searched PubMed, Global Health, the VHL Regional Portal, Epistemonikos, Health Systems Evidence, and EBM Reviews as well as preprints, regional repositories, and rehabilitation organisations websites for eligible studies, from database inception to search date in June 2022. SELECTION CRITERIA: We included studies that used qualitative methods for data collection and analysis; and that explored patients, caregivers, healthcare providers and other stakeholders' experiences, perceptions and behaviours about the provision of in-person home-based rehabilitation and home-based telerehabilitation services responding to patients' needs in different phases of their health conditions. DATA COLLECTION AND ANALYSIS: We used a purposive sampling approach and applied maximum variation sampling in a four-step sampling frame. We conducted a framework thematic analysis using the CFIR (Consolidated Framework for Implementation Research) framework as our starting point. We assessed our confidence in the findings using the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach. MAIN RESULTS: We included 223 studies in the review and sampled 53 of these for our analysis. Forty-five studies were conducted in high-income countries, and eight in low-and middle-income countries. Twenty studies addressed in-person home-based rehabilitation, 28 studies addressed home-based telerehabilitation services, and five studies addressed both modes of delivery. The studies mainly explored the perspectives of healthcare providers, patients with a range of different health conditions, and their informal caregivers and family members. Based on our GRADE-CERQual assessments, we had high confidence in eight of the findings, and moderate confidence in five, indicating that it is highly likely or likely respectively that these findings are a reasonable representation of the phenomenon of interest. There were two findings with low confidence. High and moderate confidence findings Home-based rehabilitation services delivered in-person or through telerehabilitation Patients experience home-based services as convenient and less disruptive of their everyday activities. Patients and providers also suggest that these services can encourage patients' self-management and can make them feel empowered about the rehabilitation process. But patients, family members, and providers describe privacy and confidentiality issues when services are provided at home. These include the increased privacy of being able to exercise at home but also the loss of privacy when one's home life is visible to others. Patients and providers also describe other factors that can affect the success of home-based rehabilitation services. These include support from providers and family members, good communication with providers, the requirements made of patients and their surroundings, and the transition from hospital to home-based services. Telerehabilitation specifically Patients, family members and providers see telerehabilitation as an opportunity to make services more available. But providers point to practical problems when assessing whether patients are performing their exercises correctly. Providers and patients also describe interruptions from family members. In addition, providers complain of a lack of equipment, infrastructure and maintenance and patients refer to usability issues and frustration with digital technology. Providers have different opinions about whether telerehabilitation is cost-efficient for them. But many patients see telerehabilitation as affordable and cost-saving if the equipment and infrastructure have been provided. Patients and providers suggest that telerehabilitation can change the nature of their relationship. For instance, some patients describe how telerehabilitation leads to easier and more relaxed communication. Other patients describe feeling abandoned when receiving telerehabilitation services. Patients, family members and providers call for easy-to-use technologies and more training and support. They also suggest that at least some in-person sessions with the provider are necessary. They feel that telerehabilitation services alone can make it difficult to make meaningful connections. They also explain that some services need the provider's hands. Providers highlight the importance of personalising the services to each person's needs and circumstances. This synthesis identified several factors that can influence the successful implementation of in-person home-based rehabilitation and telerehabilitation services. These included factors that facilitate implementation, but also factors that can challenge this process. Healthcare providers, program planners and policymakers might benefit from considering these factors when designing and implementing programmes.

Patients Place More of an Emphasis on Physical Recovery Than Return to Work or Financial Recovery.

To effectively develop patient-centered interfaces and functionality, it is essential to investigate different viewpoints on pulmonary telerehabilitation. The purpose of this study is to explore the views and experiences of COPD patients after the completion of a 12-month home-based pulmonary telerehabilitation program. Semi-structured qualitative interviews were conducted with 15 COPD patients. The interviews were analyzed using a thematic analysis approach to deductively identify patterns and themes. Patients responded with approval for the telerehabilitation system, particularly for its convenience and ease of use. This study offers a thorough investigation of patient viewpoints when utilizing the telerehabilitation technology. These insightful observations will be considered for future development and implementation of a patient-centered COPD telerehabilitation system to provide support tailored to patient needs, preferences, and expectations.

A Home Automated Telemanagement (HAT) system for in-home physical telerehabilitation of seniors with mobility limitations was developed and tested. The HAT rehabilitation system was designed to allow patients with mobility limitations to complete an individualized physical therapy plan prescribed by a physical therapist and to allow for clinicians to monitor and assist with in-home rehabilitation. We conducted a 12 week study to assess the feasibility and patient acceptance of the system. Our results showed that home-based physical telerehabilitation is feasible in seniors with mobility limitations, and it can potentially improve patient functional status significantly. The participants of the study demonstrated a very high level of support for the home-based physical telerehabilitation program.

After a cerebral stroke, survivors need to follow a neurorehabilitation program including exercises to be executed under a therapist's supervision or autonomously. Technological solutions are needed to support the early discharge of the patients just after the primary hospital treatments, by still providing an adequate level of rehabilitation. The DoMoMEA Project proposes a fully-wearable m-health solution able to administer a neurorehabilitation therapy in the patient's home or every other place established by the patient for a rehabilitation session. The exploitation of magneto-inertial measurement units only, wirelessly connected to an Android-operated device, provides robustness to different operating conditions and immunity to optical occlusion problems, compared to RGB-D cameras. Patients' engagement is fostered by the exploitation of the exergame version of the ten rehabilitation exercises, implemented in Unity 3D. Store-and-forward telemonitoring features, supported by cloud-based storage and by a web application accessible from anywhere by medical personnel and patients, enable constant transparent monitoring of the rehabilitation progresses. The clinical trial of the DoMoMEA telerehabilitation system will involve 40 post-stroke patients with mild impairment and will start as soon as the restrictions due to the COVID-19 pandemic will allow to enroll patients.