An Intensive Exercise Program Using a Technology-Enriched Rehabilitation Gym for the Recovery of Function in People With Chronic Stroke: Usability Study

Andy Kerr, Maisie Keogh, Milena Slachetka, Madeleine Grealy, Philip Rowe, Andy Kerr, Maisie Keogh, Milena Slachetka, Madeleine Grealy, Philip Rowe

Abstract

Background: Rehabilitation improves poststroke recovery with greater effect for many when applied intensively within enriched environments. The failure of health care providers to achieve minimum recommendations for rehabilitation motivated the development of a technology-enriched rehabilitation gym (TERG) that enables individuals under supervision to perform high-intensity self-managed exercises safely in an enriched environment.

Objective: This study aimed to assess the feasibility of the TERG approach and gather preliminary evidence of its effect for future research.

Methods: This feasibility study recruited people well enough to exercise but living with motor impairment following a stroke at least 12 months previously. Following assessment, an 8-week exercise program using a TERG (eg, virtual reality treadmills, power-assisted equipment, balance trainers, and upper limb training systems) was structured in partnership with participants. The feasibility was assessed through recruitment, retention, and adherence rates along with participant interviews. Effect sizes were calculated from the mean change in standard outcome measures.

Results: In total, 70 individuals registered interest, the first 50 were invited for assessment, 39 attended, and 31 were eligible and consented. Following a pilot study (n=5), 26 individuals (mean age 60.4, SD 13.3 years; mean 39.0, SD 29.2 months post stroke; n=17 males; n=10 with aphasia) were recruited to a feasibility study, which 25 individuals completed. Participants attended an average of 18.7 (SD 6.2) sessions with an 82% attendance rate. Reasons for nonattendance related to personal life, illness, weather, care, and transport. In total, 19 adverse events were reported: muscle or joint pain, fatigue, dizziness, and viral illness, all resolved within a week. Participants found the TERG program to be a positive experience with the equipment highly usable albeit with some need for individual tailoring to accommodate body shape and impairment. The inclusion of performance feedback and gamification was well received. Mean improvements in outcome measures were recorded across all domains with low to medium effect sizes.

Conclusions: This study assessed the feasibility of a holistic technology-based solution to the gap between stroke rehabilitation recommendations and provision. The results clearly demonstrate a rehabilitation program delivered through a TERG is feasible in terms of recruitment, retention, adherence, and user acceptability and may lead to considerable improvement in function, even in a chronic stroke population.

International registered report identifier (irrid): RR2-doi.org/10.3389/fresc.2021.820929.

Keywords: exercise; feasibility; feasibility study; intensive exercise; motor impairment; recovery; rehabilitation; rehabilitation technology; stroke; telehealth; telerehabilitation.

Conflict of interest statement

Conflicts of Interest: None declared.

©Andy Kerr, Maisie Keogh, Milena Slachetka, Madeleine Grealy, Philip Rowe. Originally published in JMIR Rehabilitation and Assistive Technology (https://rehab.jmir.org), 21.07.2023.

References

    1. Cieza A, Causey K, Kamenov K, Hanson SW, Chatterji S, Vos T. Global estimates of the need for rehabilitation based on the Global Burden of Disease Study 2019: a systematic analysis for the Global Burden of Disease Study 2019. Lancet. 2020;396(10267):2006–2017. doi: 10.1016/S0140-6736(20)32340-0. S0140-6736(20)32340-0
    1. Feigin VL, Forouzanfar MH, Krishnamurthi R, Mensah GA, Connor M, Bennett DA, Moran AE, Sacco RL, Anderson L, Truelsen T, O'Donnell M, Venketasubramanian N, Barker-Collo S, Lawes CMM, Wang W, Shinohara Y, Witt E, Ezzati M, Naghavi M, Murray C, Global Burden of Diseases, Injuries, and Risk Factors Study 2010 (GBD 2010) GBD Stroke Experts Group Global and regional burden of stroke during 1990-2010: findings from the Global Burden of Disease Study 2010. Lancet. 2014;383(9913):245–255. doi: 10.1016/s0140-6736(13)61953-4. S0140-6736(13)61953-4
    1. Langhorne P, Bernhardt J, Kwakkel G. Stroke rehabilitation. Lancet. 2011;377(9778):1693–1702. doi: 10.1016/S0140-6736(11)60325-5.S0140-6736(11)60325-5
    1. Dworzynski K, Ritchie G, Fenu E, MacDermott K, Playford ED, Guideline Development Group Rehabilitation after stroke: summary of NICE guidance. BMJ. 2013;346:f3615. doi: 10.1136/bmj.f3615.bmj.f3615
    1. Platz T. Evidence-based guidelines and clinical pathways in stroke rehabilitation: an international perspective. Front Neurol. 2019;10:200. doi: 10.3389/fneur.2019.00200.
    1. Stockley R, Peel R, Jarvis K, Connell L. Current therapy for the upper limb after stroke: a cross-sectional survey of UK therapists. BMJ Open. 2019;9(9):e030262. doi: 10.1136/bmjopen-2019-030262. bmjopen-2019-030262
    1. Grimley RS, Rosbergen IC, Gustafsson L, Horton E, Green T, Cadigan G, Kuys S, Andrew NE, Cadilhac DA. Dose and setting of rehabilitation received after stroke in Queensland, Australia: a prospective cohort study. Clin Rehabil. 2020;34(6):812–823. doi: 10.1177/0269215520916899.
    1. Donnellan C, Sweetman S, Shelley E. Health professionals' adherence to stroke clinical guidelines: a review of the literature. Health Policy. 2013;111(3):245–263. doi: 10.1016/j.healthpol.2013.05.002.S0168-8510(13)00127-9
    1. Mehrholz J, Thomas S, Elsner B. Treadmill training and body weight support for walking after stroke. Cochrane Database Syst Rev. 2017;8(8):CD002840. doi: 10.1002/14651858.CD002840.pub4.
    1. Braley M, De Oliveira E, Munsell M, Anantha V, Pierce J, Kiran S, Lakhan S. A phase II randomized, virtual, clinical trial of speech therapy app for speech, language, and cognitive intervention in stroke. Arch Phys Med Rehabil. 2020;101(11):E62. doi: 10.1016/j.apmr.2020.09.186.
    1. Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017;11(11):CD008349. doi: 10.1002/14651858.CD008349.pub4.
    1. Duncan PW, Bernhardt J. Telerehabilitation: has its time come? Stroke. 2021;52(8):2694–2696. doi: 10.1161/STROKEAHA.121.033289.
    1. Sweeney G, Barber M, Kerr A. Exploration of barriers and enablers for evidence-based interventions for upper limb rehabilitation following a stroke: use of constraint induced movement therapy and robot assisted therapy in NHS Scotland. Br J Occup Ther. 2020;83(11):690–700. doi: 10.1177/0308022620909023.
    1. Ngandu T, Lehtisalo J, Solomon A, Levälahti E, Ahtiluoto S, Antikainen R, Bäckman L, Hänninen T, Jula A, Laatikainen T, Lindström J, Mangialasche F, Paajanen T, Pajala S, Peltonen M, Rauramaa R, Stigsdotter-Neely A, Strandberg T, Tuomilehto J, Soininen H, Kivipelto M. A 2 year multidomain intervention of diet, exercise, cognitive training, and vascular risk monitoring versus control to prevent cognitive decline in at-risk elderly people (FINGER): a randomised controlled trial. Lancet. 2015;385(9984):2255–2263. doi: 10.1016/S0140-6736(15)60461-5.S0140-6736(15)60461-5
    1. Kerr A, Grealy MA, Kuschmann A, Rutherford R, Rowe P. A co-creation centre for accessible rehabilitation technology. Front Rehabil Sci. 2021;2:820929. doi: 10.3389/fresc.2021.820929.
    1. Eldridge SM, Chan CL, Campbell MJ, Bond CM, Hopewell S, Thabane L, Lancaster GA, PAFS Consensus Group CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ. 2016;355:i5239. doi: 10.1136/bmj.i5239.
    1. Fai Ho S, Thomson A, Moylan T, McGuckin J, Kerr A. Automated movement feedback for recovering independence in the sit-to-stand movement in an older population: a pilot randomised controlled trial of a novel system. OBM Geriat. 2019;3(4):1–10. doi: 10.21926/obm.geriatr.1904089.
    1. Kerr A, Cummings J, Barber M, McKeown M, Rowe P, Mead G, Doucet A, Berlouis K, Grealy M. Community cycling exercise for stroke survivors is feasible and acceptable. Top Stroke Rehabil. 2019;26(7):485–490. doi: 10.1080/10749357.2019.1642653.
    1. Phongamwong C, Rowe P, Chase K, Kerr A, Millar L. Treadmill training augmented with real-time visualisation feedback and function electrical stimulation for gait rehabilitation after stroke: a feasibility study. BMC Biomed Eng. 2019;1:20. doi: 10.1186/s42490-019-0020-1. 20
    1. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8(8):741–754. doi: 10.1016/S1474-4422(09)70150-4.S1474-4422(09)70150-4
    1. Biasin L, Sage MD, Brunton K, Fraser J, Howe JA, Bayley M, Brooks D, McIlroy WE, Mansfield A, Inness EL. Integrating aerobic training within subacute stroke rehabilitation: a feasibility study. Phys Ther. 2014;94(12):1796–1806. doi: 10.2522/ptj.20130404. ptj.20130404
    1. Moore JL, Potter K, Blankshain K, Kaplan SL, OʼDwyer LC, Sullivan JE. A core set of outcome measures for adults with neurologic conditions undergoing rehabilitation: a clinical practice guideline. J Neurol Phys Ther. 2018;42(3):174–220. doi: 10.1097/NPT.0000000000000229.
    1. Duncan PW, Lai SM, Bode RK, Perera S, DeRosa J. Stroke impact scale-16: a brief assessment of physical function. Neurology. 2003;60(2):291–296. doi: 10.1212/01.wnl.0000041493.65665.d6.
    1. Lang CE, Wagner JM, Dromerick AW, Edwards DF. Measurement of upper-extremity function early after stroke: properties of the action research arm test. Arch Phys Med Rehabil. 2006;87(12):1605–1610. doi: 10.1016/j.apmr.2006.09.003.S0003-9993(06)01333-5
    1. Collen FM, Wade DT, Robb GF, Bradshaw CM. The Rivermead mobility index: a further development of the Rivermead motor assessment. Int Disabil Stud. 1991;13(2):50–54. doi: 10.3109/03790799109166684.
    1. Mehrholz J, Wagner K, Rutte K, Meissner D, Pohl M. Predictive validity and responsiveness of the functional ambulation category in hemiparetic patients after stroke. Arch Phys Med Rehabil. 2007;88(10):1314–1319. doi: 10.1016/j.apmr.2007.06.764.S0003-9993(07)00446-7
    1. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77–101. doi: 10.1191/1478088706qp063oa.
    1. Pomeroy VM, Rowe P, Clark A, Walker A, Kerr A, Chandler E, Barber M, Baron JC, SWIFT Cast Investigators A randomized controlled evaluation of the efficacy of an ankle-foot cast on walking recovery early after stroke: SWIFT cast trial. Neurorehabil Neural Repair. 2016;30(1):40–48. doi: 10.1177/1545968315583724. 1545968315583724
    1. Kim SJ, Moon GJ, Bang OY. Biomarkers for stroke. J Stroke. 2013;15(1):27–37. doi: 10.5853/jos.2013.15.1.27.
    1. Miller KK, Porter RE, DeBaun-Sprague E, Van Puymbroeck M, Schmid AA. Exercise after stroke: patient adherence and beliefs after discharge from rehabilitation. Top Stroke Rehabil. 2017;24(2):142–148. doi: 10.1080/10749357.2016.1200292.
    1. Reynolds H, Steinfort S, Tillyard J, Ellis S, Hayes A, Hanson ED, Wijeratne T, Skinner EH. Feasibility and adherence to moderate intensity cardiovascular fitness training following stroke: a pilot randomized controlled trial. BMC Neurol. 2021;21(1):132. doi: 10.1186/s12883-021-02052-8. 10.1186/s12883-021-02052-8
    1. Valenzuela T, Okubo Y, Woodbury A, Lord SR, Delbaere K. Adherence to technology-based exercise programs in older adults: a systematic review. J Geriatr Phys Ther. 2018;41(1):49–61. doi: 10.1519/JPT.0000000000000095.
    1. Ostwald SK, Godwin KM, Ye F, Cron SG. Serious adverse events experienced by survivors of stroke in the first year following discharge from inpatient rehabilitation. Rehabil Nurs. 2013;38(5):254–263. doi: 10.1002/rnj.87.
    1. Nicholson S, Sniehotta FF, van Wijck F, Greig CA, Johnston M, McMurdo MET, Dennis M, Mead GE. A systematic review of perceived barriers and motivators to physical activity after stroke. Int J Stroke. 2013;8(5):357–364. doi: 10.1111/j.1747-4949.2012.00880.x.
    1. Gimigliano F, Negrini S. The World Health Organization "rehabilitation 2030: a call for action". Eur J Phys Rehabil Med. 2017;53(2):155–168. doi: 10.23736/s1973-9087.17.04746-3.
    1. Nascimento LR, Boening A, Galli A, Polese JC, Ada L. Treadmill walking improves walking speed and distance in ambulatory people after stroke and is not inferior to overground walking: a systematic review. J Physiother. 2021;67(2):95–104. doi: 10.1016/j.jphys.2021.02.014. S1836-9553(21)00018-7
    1. Sedgwick P, Greenwood N. Understanding the Hawthorne effect. BMJ. 2015;351:h4672. doi: 10.1136/bmj.h4672.

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