Requirements for home-based upper extremity rehabilitation using wearable motion sensors for stroke patients: a user-centred approach

Figures & data

Figure 1. Overview of the requirement analysis. *PACT: People Activity Context Technology.

The figure shows the four steps of the requirement analysis to identify requirements for personalised home-based UE therapy in stroke patients. After agreeing requirements, the final requirements were defined.

Table 1. Characteristics of patients and therapists who participated in interviews or focus groups.

	Stroke patients		Therapists
	Individual interviews (n = 9)	Verification interviews (n = 8)	Individual interviews (n = 9)	Focus group (n = 7)	Verification group (n = 5)
Age (years; median, IQR)	63 (48–76)	60.5 (49–76)	32.5 (31–59)	33 (31–48)	31 (24–59)
Gender (male/female)	5/4	7/1	1/8	2/5	1/4
Type of stroke (ischemic/hemorrargic)	6/3	6/2
Post-stroke phase (sub-acute/chronic)	6/3	5/3
Time since stroke (days)	65 (53–214)	150.5 (75–193.75)
Setting (primary practice/rehabilitation centre)	6/3	0/8	1/8	0/7	1/4
Profession (occupational therapist/ physiotherapist)			5/4	3/4	2/3
Stroke rehabilitation experience (years; median, IQR)			10.5 (5–37)	11 (5–25)	8 (3–37)

Table 2. Functional requirements divided into must-haves, should-haves, and could-haves.

		Themes	Requirement	Specification
Must-haves	1	Exercise principles	The system measures and stimulates the activity of the paretic UE in daily life.	The system measures daily UE activity for patients who can use their paretic UE in daily life (to facilitate, stabilise, or as the leading UE during functional activities). Sensory and/or visual triggers on the wearable sensor(s) remind and stimulate patients to use the paretic UE. The daily UE activity module can be used in combination with or individually from the exercise module.
	2	Exercise principles	The system provides and stimulates UE exercises.	The system provides UE exercises for patients who can lift their paretic UE (> 30-degree shoulder anteflexion) and have some finger extension (FMA item finger extension > 1). The UE exercise module can be used in combination with or individually from the daily activity module. For a list of required exercises: See Table 3.
	3	Exercise principles	The system provides high repetitive UE training.	The system advises a number of repetitions per exercise per session to the patient, based on the therapists’ input.
	4	Exercise principles	The system provides task-related training.	Exercises are related to patients’ most common UE functional goals. Exercises focus on the movement components of the most common functional UE tasks within patients’ goals. Exercises focus on more complex functional tasks by combining the movement components. Exercises target the paretic UE; the ipsilesional UE can be used to facilitate or stabilise.
	5	Exercise principles	The exercises allow interaction with functional objects.	Exercises allow interaction with functional objects:    a cylinder object (shape of a 0.5 L bottle), a small cube (2.5 cm3) and a pen.
	6	Exercise principles	The system allows patient-specific goal setting and provides feedback on those goals.	The therapist can set goals for daily UE activity and exercises together with the patient. Daily life UE activity goals are provided on a day and week level. UE exercise goals aim to increase the quantity or quality of exercise performance.
	7	Exercise principles	The system motivates patients to accomplish pre-set goals and adhere to the intervention. ^a	The system uses strategies to enhance patients’ extrinsic and intrinsic motivation to accomplish the training session.^a The system provides positive feedback on movement outcomes (knowledge of results).
	8	Blended care principles	The system allows blending remote therapy (e-therapy) and face-to-face therapy.	The system facilitates a minimum of two live consultations with the therapist at the start and end of the UE therapy program, with a maximum of 5 weeks between each live consultation. The system allows therapists and patients to organise additional live consultations. The system facilitates remote contact (via text or voice messages) between patients and therapists at least once a week.
	9	Blended care principles	The system allows low-threshold contact between therapists and patients.	The system allows patients and therapists to digitally contact (via text or voice messages) each other for advice, questions, or a live consultation.
	10	Exercise delivery	The system instructs the patient on performing the exercises safely and correctly.	The system instructs patients using video and audio. The patient can repeat exercise instructions as often as they want, before or during the exercises. The patient is reminded to always contact their therapist in case of new or increased UE pain before continuing the exercises. Exercises are performed in a sitting position when patients cannot walk independently in their home without the support of a walking aid or person. The system informs the patient whether the exercise was performed correctly by providing performance feedback based on performance measures.
	11	Exercise delivery	The system allows adaptation of the intervention to patient-specific needs and goals.	The therapist can manually select and adapt the number of exercises, number of repetitions, exercise level, feedback content, and feedback frequency. The therapist can make adaptations before or after a training session for the upcoming session and the next day of daily life UE activity.
	12	Exercise delivery	The system allows adaptation of the exercise level during a session.	The patient can manually adjust the exercise level based on their experience of difficulty during an exercise session.
	13	Exercise evaluation	The system provides feedback to the patient about the amount of paretic UE activity during daily life.	The feedback is related to a patient-specific goal. The feedback is provided while the system is worn, with an adjustable feedback frequency ranging from 30 min to 4 h.
	14	Exercise evaluation	The system provides feedback to the patient about the movement quantity during a session.	The system provides direct (real-time) feedback. The system measures the number of repetitions, the resting time between repetitions, the number of sets and the resting time between sets.
	15	Exercise evaluation	The system provides feedback to the patient about the movement quality during a session.	The system provides direct (real-time) feedback. See Table 3: Required exercise measures.
	16	Exercise evaluation	The system allows therapists to remotely evaluate the daily activity, quantity and quality of exercise sessions performed by patients.	The therapist can evaluate patients’ exercise performance and results in a remotely accessible therapist interface. The therapist can evaluate patients’ exercise once a week and more if needed. Exercise results are presented over time to allow long-term evaluation and comparison. Exercise results are updated each day after an exercise session.
	17	Usability	The system is easy for patients to use; the patient can use the system preferably independent from a healthcare professional or caregiver.	The number of sensors is limited and easy to apply and remove by patients. The sensor configuration is easy to perform by patients. The patient is allowed to use their ipsilesional UE to apply, remove and set-up of the system. The functionalities are limited as possible. The functionalities and the layout is comparable with standard and widely used software. Video and audio instructions are basic and not distractive. The patient with complex comorbidities and cognitive and/or visual impairments can use the system with the help of a caregiver.
	18	Usability	The system is easy to use for therapists.	The therapist interface is easily accessible and can be used on a PC, tablet or laptop. The functionalities and the layout is comparable with standard and widely used software.
Should-haves	19	Exercise principles	The system provides shoulder stabilising exercises.	The therapist can select minimally three different (anteflexion, abduction and rotation) exercises aiming to improve shoulder stabilisation. The patient gets feedback on shoulder compensatory movements during these exercises. The system provides feedback on the quality of the shoulder movements during stabilising exercises.
	20	Exercise principles	The system provides strengthening exercises.	The therapist can select exercises aiming to improve UE strength. The system provides weights or resistance bands to intensify the exercise. The system provides feedback on the quality of the movement during strengthening exercises.
	21	Exercise principles	The system provides total task practice with feedback on accomplished tasks.	The patient can exercise a selection of the most common functional tasks, as reported by patients. The system provides feedback to the patient on whether a functional task is accomplished.
	22	Exercise delivery	The exercises allow interaction with daily life objects in the patient’s environment.	Exercises allow the use of various functional objects patients use in their daily lives. Exercise objects are patient and context-specific.
	23	Exercise delivery	The system provides optional visual and auditive elements during the exercises.	The therapist can add visual and auditive elements to increase the cognitive load and the complexity of an exercise.
	24	Exercise evaluation	The system presents reference values on daily life activity by measuring the activity of the ipsilesional UE.	The system measures the daily life activity of the paretic UE and the ipsilesional UE. The system provides feedback on the ratio between the paretic UE and ipsilesional. The system provides the therapist with insight into the ratio.
	25	Exercise evaluation	The system summarises exercise performance results for patients after each exercise session.	The system provides insight into the patient’s exercise performance results in UE activity over time. Results are visualised and clearly presented.^a
	26	Exercise evaluation	The system summarises daily UE activity results for patients.	The system provides the patient insight into daily activity results over time. Results are visualised and clearly presented.^a
	27	Exercise evaluation	The system presents reference values for the exercise measures in the therapist overview.	The therapist can compare patient and control values for each exercise measure.
	28	Usability	The system allows use by people with foreign languages.	The system is available in various languages, and language settings can be changed to at least: Dutch, English, Polish, Turkish and Arabic. The system can be used and understood without knowledge of a particular language (e.g., the system uses symbols and animations to instruct patients).
Could-haves	29	Exercise delivery	The system allows intervention adaptation to patient-specific needs and goals based on the patient’s previous performance during a session.	The system can adapt the exercise level based on a patient’s exercise performance measures during an exercise session.
	30	Exercise evaluation	The system allows video recording and video sharing with the therapists.	The patient can record while performing an exercise. The patient can share the video recording with the therapist via the patient interface.
	31	Exercise evaluation	The system provides feedback on movement quality during daily life.	The system provides feedback on quality measures of movement components measured during daily life UE activity.
	32	Usability	The system proposes a set of exercises and quantitative and qualitative measures for each exercise based on the patient’s functional goals.	The system proposes exercises and measures for each of the selected exercises relevant to a specific patient goal. The therapist can adjust the measures used to provide feedback to the patient or for evaluation by the therapist.
	33	Usability	The therapist interface is available in the electronic patient record.	The therapist interface can be viewed by the health care professionals in the electronic patient record that the rehabilitation provider uses.

UE: upper extremity; FMA: Fugel Meyer Assessment.

^aItems require design-oriented research and are not described in detail in this paper.

Table 3. Exercises and exercise measures for each movement component (A) and functional combinations of movement components (B).

	Movement variation	Measures
		Must have	Should have	Could have
A. Movement components
Reach
Reach to a cylinder object and touch it. The object can be in different positions; the patient can reach in different directions: vertical ‘high’ (90–160 degrees shoulder flexion), vertical ‘low’ (< 90 degrees shoulder flexion), horizontal abduction (0–90 degrees horizontal shoulder abduction), horizontal adduction (90–130 degrees shoulder adduction).	reach distance; reach direction; velocity	trunk and shoulder compensatory movements; reach distance	touch accuracy; smoothness	ROM shoulder, (anteflexion, abduction, adduction); ROM elbow (flexion-extension)
Reach to a point and touch it. (Moving) targets are shown (on a digital screen). The patient touches the targets with preferably the index finger. Targets can appear and disappear in different sizes and speeds.	velocity; target size	trunk and shoulder compensatory movements; reach distance	touch accuracy; smoothness	ROM shoulder, (anteflexion, abduction, adduction); ROM elbow (flexion-extension)
Grasp
Grasp a cylinder (cylinder grasp).	position of the object; dosage of grip strength	timing of hand opening and closing; grip strength	ROM index finger and thumb; trunk and shoulder compensatory movements
Grasp a small cube (three-point grasp).	position of the object; dosage of grip strength	timing of hand opening and closing; grip strength	ROM index finger and thumb; trunk and shoulder compensatory movements
Hold & release
Hold and release a cylinder (cylinder grasp) on the system-indicated moments, durations and force.	position of the object; velocity; dosage of grip strength	timing of hand opening; grip strength	trunk and shoulder compensatory movements
Hold and release a small cube (three-point grasp) on the system-indicated moments, durations and force.	position of the object; velocity; dosage of grip strength	timing of hand opening; grip strength	trunk and shoulder compensatory movements
Displace, lift & positioning
Lifting a cylinder, transport it in different directions (< 90 degrees shoulder flexion, horizontal 0–90 degrees horizontal shoulder adduction, horizontal 90–130 degrees shoulder adduction) while keeping it in an upright position	transport direction; transport distance; velocity; dosage of grip strength	object tilt (in degrees); transport distance; smoothness; grip strength; trunk and shoulder compensatory movements	ROM shoulder, (anteflexion, abduction, adduction); ROM elbow (flexion-extension)	Velocity
Lifting a cylinder object, transport it in different directions (< 90 degrees shoulder flexion, horizontal 0–90 degrees horizontal shoulder abduction, horizontal 90–130 degrees shoulder adduction) while keeping it in an upright position and tilting the object on the by the tablet indicated place, moment and speed.	transport direction; transport distance; velocity; dosage grip strength; object tilt degrees; object tilt timing	object tilt (in degrees); transport distance; accuracy of object tilt; smoothness; grip strength; trunk and shoulder compensatory movements	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension); ROM wrist (pronation-supination)	Velocity
Push/pull/shove
Moving the palmar side of the hand over the back of the head	velocity	trunk and shoulder compensatory movements; smoothness	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension); velocity of the hand
Moving the palmar side of the hand over the back	velocity	trunk and shoulder compensatory movements smoothness	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension); velocity of the hand
Manipulate
Hold a pen in hand and perform 'writing’ exercises: following lines straight and curled, writing the alphabet in block letters.	velocity, size of the lines and letters	smoothness; grip strength	Velocity	ROM index finger and thumb
Grasp small objects (small pegs) between fingers (optional: turn the pegs around) and put each of them separately in a small container	velocity	smoothness; grip strength	Velocity	ROM wrist (pronation- supination); ROM index finger and thumb
B. Combination Exercises
Reach + grasp (cylinder or 3-point grasp)
Reach to the object (cylinder or cube) and grasp it (cylinder or 3-point grasp). The object can be placed in different positions; the patient should reach in different directions (high (90–160 degrees shoulder flexion), low (< 90 degrees shoulder flexion), horizontal 0–90 degrees horizontal shoulder abduction), horizontal 90–130 degrees shoulder adduction)	reach distance; reach direction; dosage of grip strength	timing of hand opening and closing, smoothness; grip strength; trunk and shoulder compensatory movements; reach distance	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension)	ROM index finger and thumb
Reach + grasp + hold & release
Reach to the object (cylinder or cube) and grasp it (cylinder or 3-point grasp). The object can be placed in different positions; the patient should reach in different directions (high (90–160 degrees shoulder flexion), low (< 90 degrees shoulder flexion), horizontal 0–90 degrees horizontal shoulder abduction), horizontal 90–130 degrees shoulder adduction). Hold and release a cylinder object on the tablet indicated moments, durations and force.	reach distance; reach direction; dosage of grip strength; velocity	timing of hand opening and closing; smoothness; grip strength; trunk and shoulder compensatory movements; reach distance	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension)	ROM index finger and thumb
Reach + grasp + positioning, displace & lift
Reach to the object (cylinder or cube) and grasp it (cylinder or 3-point grasp). The object can be placed in different positions; the patient should reach in different directions (high (90–160 degrees shoulder flexion), low (< 90 degrees shoulder flexion), horizontal 0–90 degrees horizontal shoulder adduction), horizontal 90–130 degrees shoulder abduction). Lift the object and transport it in different directions (< 90 degrees shoulder flexion, horizontal 0–90 degrees horizontal shoulder adduction, horizontal 90–130 degrees shoulder adduction) while keeping it upright. Tilt the object on the tablet, indicating place, moment and speed.	reach distance; reach direction; dosage of grip strength; transport direction; transport distance; velocity	timing of hand opening and closing; object tilt (in degrees); smoothness; trunk and shoulder compensatory movements; grip strength; reach distance; object tilt (in degrees); transport distance; accuracy of object tilt	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension)	ROM wrist (pronation-supination); ROM index finger and thumb
Reach + grasp + push, pull & shove
Reach to the object (cylinder or cube) and grasp it (cylinder or 3-point grasp). The object can be placed in different positions; the patient should reach in different directions (high (90–160 degrees shoulder flexion), low (< 90 degrees shoulder flexion), horizontal 0–90 degrees horizontal shoulder abduction), horizontal 90–130 degrees shoulder adduction). Move the object over the back of the head.	reach distance; reach direction; dosage grip strength; velocity	timing of hand opening and closing; trunk and shoulder compensatory movements; smoothness; grip strength	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension)	ROM wrist (pronation-supination); ROM index finger and thumb; velocity of the hand
Reach to the object (cylinder or cube) and grasp it (cylinder or 3-point grasp). The object can be placed in different positions; the patient should reach in different directions (high (90–160 degrees shoulder flexion), low (< 90 degrees shoulder flexion), horizontal 0–90 degrees horizontal shoulder abduction), horizontal 90–130 degrees shoulder adduction). Move the object over the back.	reach distance; reach direction; dosage grip strength; velocity	timing of hand opening and closing; trunk and shoulder compensatory movements, smoothness; grip strength	ROM shoulder (anteflexion, abduction, adduction); ROM elbow (flexion-extension)	ROM wrist (pronation-supination); ROM index finger and thumb; velocity of the hand

Reach: intentional movement of the arm towards an object; grasp: to make a motion of seizing, snatching or clutching; hold & release: Keeping an object in a fixed position in the hand without external support and freeing the object from grip; Displace, lift & positioning: moving an object without the object being in contact with a surface in the environment and maintaining a fixed position of the shoulder, arm and hand in space; push/pull/shove: to apply force against an object with the intention to move or stabilise; manipulate: to skilfully control the position of an object using the fingers [36]. ROM: Range of Motion.

Lemmens RJM, Janssen-Potten YJM, Timmermans AAA, et al. Arm hand skilled performance in cerebral palsy: activity preferences and their movement components. BMC Neurol. 2014;14:52.

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