Recommendations for studies on dynamic arm support devices in people with neuromuscular disorders: a scoping review with expert-based discussion

Figures & data

Table 4. Literature search terms, criteria, and strings.

	Search terms	Inclusion criteria	Exclusion criteria
Population	Neuromuscular Diseases Neuromuscular Manifestations Muscular Dystrophies Musculoskeletal Diseases Disabled Persons	Neuromuscular Diseases Neuromuscular Manifestations Muscular Dystrophies Musculoskeletal Diseases Disabled Persons	Animals Cadaver
Impairment	–	–	Amputees Fractures, Bone Cognition Disorders Muscle-Tendon problems
Region	Upper Extremity Shoulder Arm Elbow Scapula	Upper Extremity Shoulder Arm Elbow Scapula	Lower Extremity Spine Hand Head Psychological*
Intervention	Self-Help Devices Orthotic Devices Gravity Compensation Exoskelet* Robot* Support Devices Arm Support Arm Assistance	Self-Help Devices Orthotic Devices Gravity Compensation Exoskelet* Robot* Support Devices Arm Support Arm Assistance	Medicine General Surgery Electrical Stimulation Drug Therapy Transcranial Magnetic Stimulation Magnetic Field Therapy Virtual Reality Exposure Therapy
Evaluation	Investigative Techniques (PubMed only)	Investigative Techniques Activities of Daily Living Range of Motion, Articular Torque Reachable Workspace Joint Loading Muscle Activity Body Function Activity	–
Others	–	–	Publication Date: 01-01-2000 up until 30-06-2020
Search string (PubMed)	(Neuromuscular Diseases[All Fields] OR Neuromuscular Manifestations[All Fields] OR Muscular Dystrophies[All Fields] OR Musculoskeletal Diseases[All Fields] OR Disabled Persons[All Fields]) AND (Upper Extremity[All Fields] OR Shoulder[All Fields] OR Arm[All Fields] OR Elbow[All Fields] OR Scapula[All Fields]) AND (Self-Help Devices[Title/Abstract] OR Orthotic Devices[Title/Abstract] OR Gravity Compensation[Title/Abstract] OR Exoskelet*[Title/Abstract] OR Robot*[Title/Abstract] OR Support Devices[Title/Abstract] OR Arm Support[Title/Abstract] OR Arm Assistance[Title/Abstract]) AND (Investigative Techniques[All Fields]) AND ("2000/01/01"[PDAT] : "2020/06/30"[PDAT])
Search string (Web of Science)	ALL=(Neuromuscular Diseases OR Neuromuscular Manifestations OR Muscular Dystrophies OR Musculoskeletal Diseases OR Disabled Persons) AND ALL=(Upper Extremity OR Shoulder OR Arm OR Elbow OR Scapula) AND TS=(Self-Help Devices OR Orthotic Devices OR Gravity Compensation OR Exoskelet* OR Robot* OR Support Devices OR Arm Support OR Arm Assistance)Timespan = 2000–2020

Table 3. Tabulation and summary of literature (L) and expert views (E) and synthesis of research recommendations.

ICF component	Category	Sub-category	Motor Capacity	Motor Capability	Motor Performance	Expert views (E) and literature findings (L)	Synthesised research recommendations
Body function	Muscle	Activity	1	–	–	E: for which muscles can a DAS reduce muscle activity? L: activity was reduced in the Trapezius, Deltoid, and Pectoralis Major muscles.	Explore the effects of external force generated by DAS on muscle function of the musculoskeletal system. Determine whether an external force introduces a burden on other muscles or if it relieves pain and stiffness. Investigate the relation between muscle effort reduction and muscle coordination of the shoulder girdle. Prescribe user strength requirements to a device.
		Coordination	–	–	–	E: does a DAS require compensatory strategies?
		Fatigue	–	–	10	E: how can we measure and prevent fatigue? L: no findings available from ongoing studies.
		Pain	–	–	–	E: can a DAS relieve muscle pain?
		Stiffness	–	–	–	E: can a DAS reduce muscle stiffness?
		Strength	4	–	–	E: what are required strengths to operate a DAS? L: potential DAS effects are related to residual muscle groups’ strength.
	Joint	Kinematics	1, 2, 4, 5, 6	–	–	E: can we map the differences in motion w/o DAS? L: a DAS positively affects the reachable workspace.	Explore the effects of an external force generated by DAS on the joints of the musculoskeletal system. Investigate the relation between improvements in joint load reduction and mobility and joint stability, pain, and stiffness. Investigate the relationship between levels of external force, joint loading, and mobility across the range of motion.
		Kinetics	3	–	–	E: can we map the interacting forces for motions with a DAS? L: gravity compensation reduces joint torques and thus effort.
		Pain	–	–	–	E: can a DAS relieve joint pain?
		Stiffness	–	–	–	E: can a DAS overcome joint rigidity and feelings of stiffness?
	Upper body	Functionality	7, 8, 9, 10	–	–	E: can we distinguish different aspects of upper body functionality improvements? L: the DAS had a large positive effect on most items. No findings available from ongoing studies.	Investigate the effects of a DAS on the upper body as a whole by including other regions than the shoulder area. Explore what can be improved by integrating devices that support other regions than the shoulder area.
		Hand/Wrist function	–	–	–	E: what is the influence of a DAS on hand/wrist function?
		Motion/Posture	2	–	9	E: how can we support natural motion/support? L: an integrated DAS with trunk support positively affected participants’ posture. No findings available from ongoing studies.
	Population description	Disease progression	–	–	–	E: can we expand knowledge of the (active) population on muscle/joint/upper body aspects?	Limited knowledge on disease progression is presented on a population of DAS users. Perform a review on disease progression in NMD on functionality and disability.
	Others	Short term tests	–	–	–	E: current measurements are too time-consuming for participants.	Performance tests are considered too long due to the rapid onset of fatigue within this population. Furthermore, disease progression or DAS effects are not captured to a sufficiently distinctive level in a cross-sectional design. Develop tests which require less from the population and can be applied on multiple occasions.
		Long term tests	–	–	8,9	E: cross-sectional studies are not representative for disease progression. L: no findings available from ongoing studies.
		Test accuracy and discriminative properties	–	–	–	E: current methods do not capture disease progression properly enough.
Activity & Participation	User-device interaction	Body function aspects	1-10	–	9, 10	E: what are the effects of a DAS on body function aspects and how do they interact? L: a DAS reduces efforts and increases reachable workspace, depending on residual muscle strength. No findings available from ongoing studies.	Research should combine multiple aspects to investigate interactions between body functions. Relate the performance of ADL to body functions and identify areas for device development. Identify non-usage in daily life as an indicator for disease progression. Monitor performance and identify negative adaptations.
Activity & Participation		Functionality	5, 7, 8, 9, 10	–	8, 10	E: what types of ADL are possible, impossible, or limited w/o a DAS? L: the DAS positively affected the collectively measured ADL. No findings available from ongoing studies.
		Quantified device utilisation			–	E: can we quantify device utilisation and recognise non-usage?
		Quality of performance			9, 10	E: can we monitor performance of ADL at home? L: no findings available from ongoing studies.
	Population description	Needs and goals		–	9, 10	E: what are the needs and goals of people with NMD? L: no findings available from ongoing studies.	Describe the population so it connects the desired motor capabilities and performance to the capacity. Integrate aspects of personal and environmental factors.
		Functionality	5, 7, 8, 9, 10	–	8, 9, 10	E: what types of ADL are people with NMD capable of and do they perform those at home? L: observations revealed participant-specific possibilities for ADL. No findings available from ongoing studies.
	Others	Ambulant/Body mounted	–	–	–	E: what is the influence of being ambulant and/or wearing a body-mounted DAS on device utilisation?	User-device interaction evaluations should be applicable to a large variety of users, yet discriminative. It is suggested to have a flexible and tailored method, such as wearable sensors, to measure continuously in varying settings.
		Test accuracy and discriminative properties	–	–	–	E: current methods are limited in capturing user-device interaction properly.
Environmental and Personal factors		Home setting and outdoors		–	8	E: what are factors in the user’s environment that influence the user-device interaction? L: perceived facilitators were related to independence stimulated by internal and external motivation. Perceived barriers were related to disease progression, support from experts, and integrating DAS use with the use of a wheelchair.	Environmental and personal factors are under-investigated influencers of user-device interactions. Studies should consider barriers and facilitators for activity monitoring.
		Psychological drives			–	E: what is the influence of motivation on user-device interaction?
		Distribution of energy			8	E: can we estimate energy costs through activity monitoring and effort reduction by DAS? L: endurance was enhanced with the use of a DAS, but depended on the residual capabilities of the user.

Current evidence, or knowledge gaps, within experts’ interests were indicated in each cell by the reference number(s) or a dash, respectively. Blank cells either lacked experts’ interests or were considered theoretically impossible. NMD: NeuroMuscular Disorders; ADL: Activities of Daily Living; DAS: Dynamic Arm Support; w/o: with and without. 1. (Dunning et al. [18]) 2. (Kooren et al. [19]), 3. (Essers et al. [20]), 4. (Estilow et al. [21]), 5. (van der Heide et al. [22]), 6. (Haumont et al. [23]), 7. (Lebrasseur et al. [24]), 8. (Cruz et al. [25]), 9. (Bendixen [26]), 10. (Pedrocchi [27]).

Figure 1. Flowchart of mixed-methods process.

Table 1. Characteristics of included studies.

Reference	Research aim	Study design, population, DAS, and tasks	Outcome parameters and interpretations	Research recommendations
Dunning (2016)	To explore the effect of the JAECO WREX with trunk motion capability on the total range of motion and balancing quality of the arm support.	SD: Cross-sectional P: Healthy (N = 3) DAS: JAECO WREX with prototype trunk motion capability T: Functional task and ADL (single joint motions, reaching and touching various places, and drinking w/o DAS)	Range of motion (kinematics) Normalised muscle activity levels Range of motion increased by 10% and less muscle activity is needed with support.	Use the same degrees of freedom in the DAS as a human arm which allows for better alignment and natural behaviour. The effect of a body-bound DAS with trunk motion capability was perceived as important by both healthy subjects and three DMD patients who shortly tried the DAS without measurements. Movements were easier and more natural to perform and DMD patients mentioned that it also allowed for making compensatory movements.
Essers (2013)	To compare the influence of gravity compensation between joint moments in populations performing a reaching task.	SD: Cross-sectional P: Muscular Dystrophy (Facioscapulohumeral Dystrophy) (N = 3) and Healthy (N = 3) DAS: SLING T: Functional tasks (reaching at shoulder level w/o DAS)	Joint moments (kinetics) Execution time (kinematics) Joint moments were lower with DAS but execution time was longer.	Designing better support devices should include biomechanical considerations. Further research should be focussed on expanding the investigation on the influence of gravity compensation in muscular dystrophy subjects in order to quantify the real benefits of an arm support device.
Estilow (2018)	To evaluate the efficacy of the JAECO WREX on improvement of active range of motion of the upper extremity and ADL performance.	SD: Cross-sectional P: Muscular Dystrophy (Duchenne) (N = 9) DAS: JAECO WREX T: Functional task and ADL (active shoulder motions, eating/drinking, simulated facial grooming, and item retrieval w/o DAS)	Active range of motion (kinematics) Manual muscle strength testing Improvements in active range of motion of shoulder and elbow joints depended on the patients’ strength.	Further exploration of agonist and antagonist strength ratios is needed with respect to the muscle groups that receive assistance. Longitudinal studies are necessary to evaluate the WREX’s regarding muscle strength and active range of motion preservation. Future research should include the use of diagnosis-specific measures and an ordinal ADL scale. In addition, research is needed to identify clinical measures that predict successful performance with the WREX to allow clinicians to appropriately evaluate and recommend the WREX for patients with neuromuscular diseases.
Haumont (2011)	To describe the JAECO WREX and to assess the functional improvement in the upper extremity.	SD: Cross-sectional P: Arthrogryposis Multiplex Congenita (N = 1) and Spinal Muscular Atrophy (N = 2) DAS: JAECO WREX T: Functional tasks and ADL (shoulder motions, reaching, and eating/drinking w/o DAS)	Range of Motion (kinematics) There was greater mobility of the upper extremity in motions against gravity with the DAS.	Future DAS should assist in pronation or supination as these motions are an integral part of the feeding movement.
Heide (2017)	To evaluate the Motion and Muscle Ambulatory Activity System at a home setting and investigate range of motion and ADL performance w/o DAS.	SD: Cross-sectional P: Stroke (N = 2), amyothophic lateral sclerosis (N = 1), muscular dystrophy (N = 1), and spinal stenosis (N = 1) DAS: Top-help and SLING T: ADL (reaching and eating/drinking w/o DAS)	Range of Motion (kinematics) Shoulder range of motion increased with DAS but varied greatly between individuals.	To understand the real effects of these devices it is recommended to take this individual variation into account and that benefits are also assessed in a broader daily life context. Insight into benefits of DAS and influencing factors could support the provision and the selection process of DAS.
Kooren (2015)	To develop, pilot test, and present the characterisation and validation of the A-gear.	SD: Cross-sectional P: Duchenne (N = 3) and Healthy (N = 1) DAS: A-gear (prototype) T: Functional tasks and ADL (shoulder and elbow motions, eating/drinking, use phone/computer, self-care, and PUL score w/o DAS)	Range of Motion (kinematics), Distance covered (kinematics), Comfort (self-reported) PUL score was increased with less compensatory movements. Arm movements forward and upward became easier. The DAS was comfortable.	One-hundred percent weight compensation is not always preferred by patients. One of the patients wanted less supporting force, which felt more comfortable to him. The reduction of compensatory movements is very important, as compensatory movements consume a lot of energy and therefore they restrict the endurance to perform daily activities. Two sided support is preferred to avoid a skew posture. Forward lean capability is much appreciated. DAS preferably does not run between arm and trunk, or add considerable volume underneath the forearm and elbow. Such components create an uncomfortable environment for arm relaxation and can clash with tabletops.
Lebrasseur (2019)	To evaluate the usability of the Gowing power-assisted arm support.	SD: Cross-sectional P: Multiple sclerosis Spinal (N = 3), muscular atrophy (N = 3), and muscular dystrophy (N = 3) DAS: Gowing T: Functional tasks and ADL w/o DAS	Disabilities of the Arm, Shoulder and Hand (DASH) Modified Upper Extremity Performance Test for the Elderly (TEMPA) Quebec User Evaluation of Satisfaction with assistive Technology (QUEST) The DAS improved TEMPA scores and two third were quite or very satisfied with the device.	Different actively actuated devices could be compared in manual tasks and in the long-term to assess long-term benefits. Future designs should include hand exoskeleton or wrist support on a DAS to investigate the influence of fine movement improvements. Proper use of DAS in research might depend on correct installation and should receive attention in the experimental setup.
Cruz (2020)	To examine Armon Edero and Multilink with Elevation Assist on upper limb function and ADL.	SD: Cross-sectional P: Muscular dystrophy (Duchenne) (N = 4) DAS: Armon Edero and Multilink with Elevation Assist T: Functional tasks and ADL w/o DAS	PUL score Duchenne Muscular Dystrophy Upper Limb function Patient Reported Outcome Measure (DMD UL PROM) Semi-structured interviews PUL mid-level score was increased, but distal level score decreased with DAS. Mostly eating and drinking was enhanced. Decline in strength was the main reason for discontinuation.	ROM and standardised assessment measures do not necessarily predict the degree of functional improvement possible with DAS use in real life settings. Both objective and subjective outcome measures should be used when evaluating the effectiveness of a DAS. Input may also be required for ongoing support from a clinician and/or supplier experienced in DAS fitting and adjustment, to ensure issues can be addressed in a timely manner as the disease progresses. Future DAS designs should focus on independent stabilisation of the arm when it is positioned in the DAS and improve sensitivity between DAS tension levels. Furthermore, a DAS should fit within the existing wheelchair dimensions and allow the DAS to be secured in a fixed position when not in use to offer increased device utility and improve user experience.

SD: study design; P: population; N: number of participants; T: tasks; DAS: Dynamic Arm Support; w/o: with and without.

Table 2. Characteristics of ongoing studies.

Reference	Research title and aim	Study design, population, DAS, and tasks	Outcome parameters	Research relevance
Bendixen (2019)	Title: Use of Dynamic Arm Support Devices for Upper Limb Function in Non-Ambulatory Men With DMD Aim: To promote participation in activities of daily living in non-ambulatory individuals with DMD with upper extremity weakness.	SD: Longitudinal, randomised, and interventional P: Duchenne Muscular Dystrophy DAS: Armon Ayura and JAECO WREX T: Baseline (2 weeks) Device trial (4 weeks) Post device trial (2 weeks)	Primary: Change in Upper Extremity Acceleration using Actigraph Change in Upper Extremity Position using Actigraph Secondary: Goal Attainment Scale Physical Motor Assessment PUL score	Upper extremity performance will be further quantified with use of a physical motor assessment, the PUL assessment, and patient reported outcomes. Data gleaned will provide important knowledge and objective results regarding the potential benefit of DAS in individuals with DMD with limited functional use of their upper extremities.
Pedrocchi (2019)	Title: USEFUL: User-centred Assistive SystEm for Arm Functions in neUromuscuLar Subjects Aim: To field-test the improvement in arm functions provided by DAS and assessing their impact to users' quality of life and independence	SD: Longitudinal, cross-over, and interventional P: Muscular Dystrophies (Duchenne, Becker, Limb-Girdle Type 2) DAS: Armon Ayura and JAECO WREX T: Baseline (cross-sectional) Short Training DAS 1 (3 days) Domestic use DAS 1 (2 weeks) Short Training DAS 2 (3 days) Domestic use DAS2 (2 weeks)	Primary: PUL score Secondary: Motor Function Measures scale Brooke scale ABILHAND PedsQL PROMIS FATIGUE Personal Adjustment and Role Skills Scale III Technology Acceptance Model System Usability Scale	Field-testing is essential to ensure a widespread accessibility to these devices for most of the potential users, possibly providing health providers with direction and guidance towards Health Technology Assessment.

DMD: Duchenne Muscular Dystrophy; SD: Study Design; P: Population; T: Tasks; DAS: Dynamic Arm Support.

Table 5. Expert views as tabulated keywords from the collective focus group interviews. DAS: Dynamic Arm Support, w/o: with and without.

ICF model	Impairments & Limitations	Effectiveness & Requirements	Previous projects & Remaining questions	Research priorities
Body functions	Common: Difficulty with performing motions against gravity; shoulder pain; muscle weakness/ pain/ fatigue, coordination; inactivity of muscle groups or other detrimental effects due to compensational strategies; joint rigidity; hand function Solved: Amount of range of motion; shoulder pain; muscle fatigue and coordination; posture Unsolved: Larger range of motion; hand function; muscle weakness/ pain/ fatigue (required residual forces for device usage); finer coordination; integration with wrist support; joint rigidity; DAS induced inconvenience; limited shoulder motion/ stabilization; pronation/ supination	Effective: Device usage is intuitive; it supports and motivates usage of affected side; effectiveness is mostly subjective Ineffective: DAS has limited range of motion; it requires additional energy; disease and device utilization shows progression; not used as intended according to specifications; user has compensation strategies; ineffectiveness is mostly subjective Minimum requirement: DAS has controlled interaction from joints (shoulder, elbow, wrist driven control); promotes normal posture, natural motion, and range of motion especially above shoulder/ head level; provides adaptive support; usable in training; frictionless; usage is intuitive; provides shoulder support; decreases fatigue	Previous projects: Influence of gravity compensation; basic demands for ADL tasks (gravity compensation, range of motion); arm positioning/ balancing; biomechanical interaction with support; force transposition from DAS to user; head support; arm brace for shoulder stabilization; improvement for proprioceptive feedback Remaining questions: Supporting posture; interaction disease-device; kinematic profile (abilities, limitations); fatigue/ pain/ residual strength; required residual force/ strength; compensation support and muscle rigidity; feedback regarding shoulder motion	Interests: Biomechanics of usage (interaction forces, utilization of range of motion, feedback regarding shoulder motion as therapy tool); interaction ambulant user-device; fatigue Device user’s interests: Upper extremity performance (RoM/ motion progression, frequency of usage, speed/effort, training, time/ effort); how to prevent inactivity/ fatigue Gaps: Biomechanical interaction user-device (forces); required residual strength capacity; supporting natural posture/ motion; accurate description/ indication disease progression; need for short-term measurements; adequate tests for pain/ stiffness/ fatigue/ functionality in combination with DAS; cross-sectional tests are not representative, need for longitudinal tests
Activity	Common: Limitations in repetitions; independence/ self-care (eat/ drink, writing); interaction with environment; DAS acceptance (embarrassment); computer work Solved: Certain level of dependency/ self-care (eat/drink, computer work) Unsolved: Activities outside range of motion; interaction with environment; natural motion hand to mouth after elevation (eating/ drinking, pouring a drink); writing; easy don/ doff; limited activities supported; problems with computer work still exist; other types of DAS are sometimes better (adjusted spoon), perhaps a combination is necessary	Effective: DAS changes users’ inability to ability or improves a realistic user need (repetitions); completing tasks within acceptable range of motion at comfortable level Ineffective: Mostly subjective Minimum requirements: Mostly subjective; DAS should support independent self-care; improvement of ADL; allow control of wheelchair; enable writing; motivate users	Previous projects: Role of DAS in independency/ self-care; motion intention detection; obscure interaction with environment; evaluation of ADL support; motion freedom w/o DAS Remaining questions: What are the kinematic profiles (activities and limitations) w/o DAS; how to increase the set of supporting activities	Interests: What are individuals’ needs or goals; device usage duration/ frequency; area map of gravity compensation linked to range of motion; identification and performance evaluation of self-care activities at home (eating/ drinking, computer/ tablet usage) Device user’s interests: Recognizing non-usage; types of activities (can/not and w/o DAS)/ activity profile; user-device/needs-specs match; distribution of energy over activities/ motivation; activity monitoring with moderated feedback (users indicate they are aware of their activities/ energy) Gaps: Recognizing use/ non-use; activities/ functional capacity w/o DAS in home setting with respect to ADL needs; description of active population; environmental factors
Participation	Common: Dependency on caregiver; trying to blend in; reaching individual goals; inactivity due to body function problems; age and disease dependent; eating at a restaurant Solved: Certain level of dependency/ self-care (eat/ drink at restaurant); reaching out hand for contact Unsolved: Integration with wheelchair; trying to blend in/ embarrassment; limited social contact due to caregiver dependency and hand contact; DAS not accessible/ transportable	Effective: Mostly subject to user needs and social context; if a user becomes more independent Ineffective: Mostly subject to user needs and social context; progression of usage; environmental factors limiting usage Minimum requirements: DAS is transportable; allows interaction with environment; double-sided DAS to stimulate both arms	Previous projects: Inquiring user needs; ADL and home usage; Quality of Life; user-DAS match procedure/ evaluation (does it work and can it be optimized?) Remaining questions: Relation between device usage and psychomotor factors (motivation, mood, good/bad motion profiles, energy costs); environmental factors (home setting and outdoors) and personal factors; aesthetics/ embarrassment	Interests: Device usage in home settings; DAS in ambulant users as body mounted Device user’s interests: Psychological drives; social interaction; experiencing normal puberty; barriers of confrontation Gaps: What is important/ positive for users; individual wishes and possibilities; quality of performance at home
Other	Common: Users are very intuitive with compensational strategies and masking problems Solved: Mounted to wheelchair provides constant access Unsolved: Aesthetics/ hardware/ size/ transportation; DAS not adaptive to disease progression; limited knowledge from user/ therapist on DAS; costs/ repair; user-device mismatch due to shortcomings in selection procedure/ disease progression; variation in user capabilities/ no universal method	Effective: DAS wear/utilization (actual usage); acceptation; user motivation Ineffective: DAS prototypes that do not reach the market Minimum requirements: Mechanistic balance; application to monitor user-device match; smaller size; smaller increments/ adjustments for gravity compensation; adaptive support; proper manual/ guidance device usage	Previous projects: General DAS information (also for insurance companies); involvement of young users Remaining questions: Fine-tuning prototypes with simulation modeling; transposing applied force to user; reducing internal friction/ required force from user; terminology of all DAS related items; aspects of user-device match (individual assessments; differences between DAS)	Interests: Time DAS motor is active; commands send to readjust motors; integration of devices and other DAS; aesthetics; use/ disuse and affected/ unaffected side; Device user’s interests: Mostly subjective; allocate time to develop DAS acceptance in selection procedure Gaps: Problem cases; intensity of device utilization; DAS as measuring tool; matching wishes/ needs users; limited knowledge from care providers about DAS; structured method to decide which DAS and when; easy yet universal device for users and therapists; limited choice in DAS (insurance/ costs); test period at home; communication between professionals should improve to find the best user-device match Other: Psychomotor and complexity of advice procedure should be taken into account; need to know actual usage regarding ADL; what are other unknowns; user-device adaptation; therapy to improve usage; website with all DAS information; adequate tests to indicate need for DAS; more research for practical things (selection procedure, costs, aesthetics); rehabilitation can observe ADL but progress is training dependent

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