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Technical innovations have the potential to compensate for loss of upper-limb motor functions after stroke. However, majority of the designs do not completely meet the needs and preferences of the end users. User-centered design methods have shown that the attention to user perspectives during development of assistive technology leads to devices that better suit the needs of the users.
To get more insight into the factors that can bring the design of assistive technology to higher levels of satisfaction and acceptance, studies about user perspectives on assistive technology for the upper limb after stroke are systematically reviewed.
A database search was conducted in PubMed, EMBASE, CINAHL, PsycINFO, and Scopus from inception to August 2017, supplemented with a search of reference lists. Methodological quality of the included studies was appraised. User perspectives of stroke survivors, carers, and health care professionals were extracted. A total of 35 descriptive themes were identified, from which 5 overarching themes were derived.
In total, 9 studies with information gathered from focus groups, questionnaires, and interviews were included. Barriers and enablers influencing the adoption of assistive technology for the upper limb after stroke emerged within 5 overarching but highly interdependent themes: (1) promoting hand and arm performance; (2) attitude toward technology; (3) decision process; (4) usability; and (5) practical applicability.
Expected use of an assistive technology is facilitated when it has a clear therapeutic base (expected benefit in enhancing function), its users (patients and health care professionals) have a positive attitude toward technology, sufficient information about the assistive technology is available, and usability and practical applicability have been addressed successfully in its design. The interdependency of the identified themes implies that all aspects influencing user perspectives of assistive technology need to be considered when developing assistive technology to enhance its chance of acceptance. The importance of each factor may vary depending on personal factors and the use context, either at home as an assistive aid or for rehabilitation at a clinic.
Stroke is one of the main causes of permanent disability [
The cause of stroke is an interrupted blood flow in the brain, either of hemorrhagic or ischemic cause, leading to disturbed generation and integration of neural commands. Depending on the area in which the interruption manifests, resulting impairments vary. Cognitive, emotional, and sensory disorders are often present after a first-time stroke; however, upper extremity weakness or hemiparesis are the most common impairments [
Technical innovations, such as assistive technology (AT), provide the opportunity to compensate for loss of motor function by supporting the upper limb during the execution of ADL [
User-centered design (UCD) methods have shown that including user perspectives during the design of AT enables development of devices that better suit the needs of the users [
There is a clear need to bring assistive device design to higher levels of acceptance. Ideally, design projects should start with addressing user needs by collecting information about the target population through focus groups, interviews, questionnaires, or observation studies (
This study, therefore, systematically reviews existing literature about user perspectives on AT for the upper extremity after stroke. The resulting insights could aid future developers in quickly determining essential user requirements that need to be addressed during the design of AT for the upper extremity after stroke to enhance its chances of acceptance by the users. The insights in this study can thus be used as a starting point for the first phase of AT development, from which developers can proceed to gather more in-depth information from their own use research, specific to their application and intended use. In the later stages of development, it remains important to involve users and incorporate UCD methods (
Typical phases of a design project. UCD: user-centered design.
An electronic database search was conducted in PubMed, Scopus, CINAHL, Embase, and PsycINFO from inception to August 2017. The search strategy used in all these databases was a combination of the following keywords and related terms (see
Assistive technology, self-help devices, and assistive devices
Rehabilitation robot, training devices, upper extremity rehabilitation equipment
Robotics
Upper extremity
Cerebrovascular accident and stroke
User requirements, a priori user perspectives, and patient preferences
Reference lists of potentially relevant papers were scanned to supplement the computerized search results. Furthermore, an internet search (Google Scholar) was performed with regard to factors that affect the use of upper extremity assistive devices in the rehabilitation setting and at home.
The following criteria were used for the inclusion of studies: (1) studies involving qualitative or quantitative research into user perspectives; (2) involvement of stroke survivors with upper extremity limitations, carers, or health care professionals (HCPs) of stroke survivors; (3) studies concerning upper extremity AT; (4) studies written in English; and (5) published, full-length, and peer-reviewed papers. The definition of ATs used in this review is “Electrical or mechanical devices designed to help people recover movement by offering direct assistance to the movement of the upper extremity,” without distinguishing between devices designed for therapeutic purposes or home use. The included studies needed to comply with all the inclusion criteria. Thus, case studies and studies including user perspectives with regard to a product that will be designed for one specific task were excluded. Moreover, studies evaluating a prototype or product were excluded. After the duplicate citations had been excluded, 2 reviewers (ALvO and GBPL) screened titles and abstracts. Full-text papers were read and summarized independently by 2 reviewers (ALvO and LCS) and discussed subsequently. A final list of papers to be included was created after consensus was reached. A third reviewer could be consulted if there was disagreement between the 2 principal reviewers (JHB in case of titles and abstracts and GBPL in case of full papers).
The Critical Appraisal Skills Program (CASP) checklist was used to appraise the methodological quality of the included studies as it can guide the evaluation of a wide range of methodologies [
Derivation and content of descriptive and analytical themes.
Overarching themes and corresponding descriptive theme | Derived from | Example expressions and citations | |
Goal-oriented exercises | [ |
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Repetition | [ |
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Intensity | [ |
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Active contribution | [ |
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Focus on hand and arm | [ |
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Motivation | [ |
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Familiarity and affinity with technology | [ |
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Digital security and privacy | [ |
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Knowledge | [ |
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Evidence-based practice | [ |
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Advice | [ |
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Time investment | [ |
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Safety aspects regulations | [ |
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Trust and expected usefulness | [ |
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Independence and self-management | [ |
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Money | [ |
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Donning/doffing | [ |
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Setup | [ |
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Initialization | [ |
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Portable | [ |
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Robustness | [ |
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Instruction on exercises | [ |
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Comfort | [ |
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Lightweight | [ |
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Ease of use | [ |
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Compliant | [ |
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Adjustment to patient | [ |
||
Technical support | [ |
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Maintenance | [ |
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Monitoring | [ |
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Feedback | [ |
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Wrongly executed movements | [ |
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Fatigue and overtraining | [ |
||
Adaptability (patient progression, task setting, and patient group diversity) | [ |
||
Physical comfort | [ |
The content of the included studies was analyzed using a structured approach, scanning for information (where available) regarding descriptive features of the population involved and the type of AT and its purpose. Subsequently, factors related to the successful or unsuccessful use of AT were collected and used as input for the analysis of this review. Therefore, information and quotations from participants under the headings
Meta-synthesis attempts to integrate results from interrelated qualitative studies. In contrast to meta-analysis, meta-synthesis has an interpretive rather than aggregating intent [
Initially, 935 references were retrieved from bibliographic databases. After removal of duplicates, 658 potentially relevant papers were screened for retrieval, of which 30 were retained for full-text review. After comparing with the selection criteria, 24 of the full-text papers were excluded. In total, 3 studies were included via additional reference searches of relevant publications. Therefore, the review includes 9 publications. The number of studies included and excluded at various stages of the review process is shown in
Flowchart of study inclusion.
Characteristics of included studies.
Source and aim of the paper (N=9) | Target population (number) | Method of data collection | Quality score |
Lam et al (2015) [ |
Stroke survivors (n=8) | Focus groups | 9 |
Nasr et al (2015) [ |
Stroke survivors (n=10) and caregivers (n=8) | In-depth interviews | 8 |
Prange et al (2015) [ |
Stroke survivors (n=5) and HCPsa (n=6) | Interviews | 5 |
Radder et al (2015) [ |
Stroke survivors (n=4) and HCPs (n=7) | Focus groups | 7 |
Hughes et al (2014) [ |
Stroke survivors and carers (n=79) and HCPs (n=120) | Questionnaire | 9 |
Sivan et al (2014) [ |
Stroke survivors (n=9) and HCPs (n=6) | Semistructured interviews | 9 |
Demain et al (2013) [ |
Stroke survivors (n=11), family caregivers (n=5), and HCPs (n=6) | Focus groups | 8 |
Hochstenbach-Waelen and Seelen (2012) [ |
HCPs (n=6) | Semistructured interviews | 4 |
Lu et al (2011) [ |
HCPs (n=233) | Questionnaire | 9 |
aHCP: health care professional.
bADL: activities of daily living.
cAT: assistive technology.
dICF: International Classification of Functioning, Disability and Health.
In total, 9 studies covering 139 stroke survivors and carers and 384 HCPs were included for analysis [
Quality scores retrieved from the CASP ranged from 4 to 9 points, with 7 studies having a score above 5 out of a possible score of 10 (
Questions of the Critical Appraisal Skills Program and the number of studies that do or do not comply with each question.
Question | Partially reported or |
|
Was there a clear statement of the aims of the research? | 9 | —a |
Is a qualitative methodology appropriate? | 9 | — |
Was the research design appropriate to address the aims of the research? | 9 | — |
Was the recruitment strategy appropriate to the aims of the research? | 5 | 4 [ |
Was the data collected in a way that addressed the research issue? | 7 | 2 [ |
Has the relationship between researcher and participants been adequately considered? | 2 | 7 [ |
Have the ethical issues been taken into consideration? | 6 | 3 [ |
Was the data analysis sufficiently rigorous? | 8 | 1 [ |
Is there a clear statement of findings? | 4 | 5 [ |
How valuable is the research? | 9 | — |
aNot applicable.
Statements and sentences from primary data were discussed and organized into 35 descriptive themes (
Therapeutic principles which are the foundation of motoric recovery should be addressed by AT. Stroke survivors and carers have remarked that intensive movement repetition needs to be promoted to regain any degree of function and to optimize recovery [
Technology aimed to be used to support the upper extremity should, therefore, offer variability in exercises and its functionality [
Over 75% of the stroke survivors, carers, and HCPs mentioned that the current practice in therapy is insufficient [
Themes in use and implementation of assistive technology (AT) for the arm and hand according to health care professionals and stroke survivors.
Before considering using an AT, the attitude toward technology in general can either play a facilitating role or form a barrier, for both the stroke survivor or end user and the HCP. Beside the before-mentioned factors to promote hand and arm performance, HCPs stress the importance of training to be motivating and challenging for stroke survivors. Motivation of stroke survivors to regain control over movements of their affected side is usually very strong [
However, mixed feelings are expressed about the affinity with technology [
Unlike the younger generation that grew up with the internet, stroke survivors are not keen on going
The decision-making process for AT consists of factors important to both stroke survivors and their carers as well as HCPs. Stroke survivors are eager to function independently during ADL through self-management [
Some of the participants are actively engaged in the search for solutions to promote arm recovery [
Although stroke survivors are willing to spend time and money on potential solutions [
When a device lacks in usability, using it will be less pleasant, which can ultimately lead to device abandonment. As previously mentioned, independence and self-management are very important to stroke survivors. Usability factors that can contribute to independent and pleasant use of the device are (1) easy to setup [
To be usable for both stroke survivors and HCPs, adjustment to the stroke survivor must be straightforward. An AT must comply with both left- and right-side affected stroke survivors [
For an AT to be used at home, stroke survivors and their HCPs want the device to be compact enough to fit in the home environment [
Stroke survivors, carers, and HCPs acknowledge that ATs can potentially benefit functioning of stroke survivors by providing intensive therapy and a means of self-management [
Individual physical and cognitive impairments that limit the ability of a stroke survivor to perform tasks should be considered when applying a system in daily practice. HCPs are worried that different types of support are needed in ADL because of the individual impairments [
Besides adjustment between stroke survivors, an AT must be adaptable to the stroke survivor’s progression over time by adapting, for example, the level of difficulty [
The previous paragraphs discussed the factors within each of the 5 overarching themes. From the included studies, it is clear that the factors can affect one another, and there are also relations between the overarching themes. The main relations between factors and themes are mapped in
ATs are designed to be used either in the clinic or during daily life in a domestic situation. Although the definition of all themes and factors will differ to some extent between an AT used in the clinic or at home, the most pronounced differences are displayed in
Factors and themes influence one another. Connecting lines indicate relationships between factors. AT: assistive technology.
The importance and interpretation of the factors may differ depending on the use context of assistive technology. ADL: activities of daily living; AT: assistive technology; HCP: health care professional.
This review comprehensively investigated user needs, preferences, and expectations that are expected to be associated with acceptance and adoption of AT for promotion of hand and arm performance after stroke. Through a meta-synthesis, 5 overarching themes were identified from literature. Factors relevant to stakeholders who may purchase or decide to use AT are covered in the following themes: (1) promotion of hand and arm performance, (2) attitude toward technology, (3) decision-making process, (4) usability, and (5) applicability in practice. Although separately presented by themes, the findings of this review highlighted the diversity and interdependence of the numerous factors influencing the chances of acceptance and adoption of AT, as illustrated in
The potential of AT for the upper limb has been recognized by stroke survivors, carers, and HCPs [
Results from this systematic review suggested that adoption of AT depends on multiple organizational and psychosocial factors and can be influenced at any stage, ranging from attitude toward technology, to the practical applicability of AT designed to promote hand and arm performance after stroke. Previously, several general design criteria with a primary focus on usability have been developed [
To bring AT design to higher levels of user satisfaction and acceptance, the interdependency of user needs as revealed in this review must be considered in every stage of the design process. This means that addressing one particular aspect of the user perspective will not be sufficient to enhance user acceptance as, that aspect, for example, usability, is influenced by other aspects as well, for example, the budget available to purchase the AT (which is in turn dependent on the use context, for instance). Therefore, when designing AT to promote hemiparetic arm and hand function, the complete spectre of themes encompassing the user perspective, as identified in this review, should be addressed.
Motivation to use AT for upper limb after stroke is driven by the wish for independence and self-management. Therefore, use of AT should have substantial added value for the performance of task-oriented activities with the upper limb. In particular, activities that the stroke survivor would normally not be able to perform without assistance should be supported by AT. ATs are seen as efficient use of therapy time [
Cost-effectiveness is seen as a determinant for the adoption of any new treatment [
The decision-making process of HCPs to purchase or use an AT, or even inform stroke survivors about AT, is largely influenced by the level of knowledge about AT and the scientific evidence present. The decision-making process of stroke survivors is influenced by the HCPs as the primary source of information about AT is their HCP whom they trust. As only 25% of the devices have been tested in stroke [
Currently, the design of robotic technology for stroke rehabilitation tends to be technology-driven [
Cherry et al [
Developers should be aware that not only the prototype but the device itself can be evaluated with users. The instructions for use, commonly created in the wrap-up phase of development when all product details are known, can have great impact on usability. Quality of the user manual can be easily improved by giving several end users some assignments with the manual to determine whether the device can be successfully applied by following the instructions. In case of digital applications, it may be possible to collect user feedback after implementation to continue to improve the device through software updates, but developers need to seriously consider any privacy concerns users have, particularly in case of digital applications.
In this review, primary or secondary end users were not included during the sessions in which the overarching themes were defined. Instead, people who have experience in the design of assistive devices participated. Their backgrounds were diverse and with their different roles in device design, it was possible to combine the results into a complete framework that is useful to both developers of AT and those who evaluate or apply AT in practice. Inconsistent terminology about AT used among studies affected our ability to identify relevant studies. An iterative search strategy tailored to the databases was supplemented by scanning the reference lists of potentially relevant papers in an attempt to identify all relevant papers.
In addition, lack of distinction between AT used for therapeutic purposes and AT used during ADL in many studies made it difficult to design a framework for both purposes separately. Although the identified overarching themes are applicable in both situations, some factors may weigh heavier than others for either therapeutic or ADL purposes. For example, for a device that is to be used at home by only 1 stroke survivor, a low adjustment time is not as crucial as when the device is intended to be used by several stroke survivors on 1 day at the clinic. In this review, both focus groups and interviews and user survey studies were included in the meta-synthesis. Although the diversity in methods to elicit user perspectives might have influenced the results or its interpretation, the aim of this review was to include all relevant information on user perspectives about AT for the upper extremity after stroke. Valuable authentic information was retrieved from user survey studies, extending the development of factors and themes with unique data from a large(
The 5 themes as identified in this study are relevant to aid future AT developers in quickly determining essential user requirements as a first step of a UCD process. As stated before, the factors identified in this review have interdependency, and the importance of a factor may change depending on the use context. Therefore, all factors need to be considered within the specific use context for which an AT is being developed. However, the reviewed studies did not indicate if certain user needs were more important than others. Therefore, insufficient information was present to rank the importance of the factors or themes, but it would be highly relevant to assess the weights that should be attributed to the identified factors and themes in future research. After identification of the user requirements, design solutions can be created and developed [
This systematic review on user perspectives on AT identified several factors and themes that reflect user preferences for AT for the upper limb post stroke, before its development. The study identified barriers and enablers influencing the adoption of AT for the upper limb after stroke within the 5 overarching themes; (1) promoting hand and arm performance; (2) attitude toward technology; (3) decision process; (4) usability; and (5) practical applicability. Besides insight into relevant aspects for design of AT, this review showed that those aspects are highly interdependent. A potential purchaser of AT goes through a decision process. Prerequisite for entering the decision process is a sufficient positive attitude toward technology and the desire to increase independence and self-management of the stroke survivor. The stroke survivor and their carer(s) prefer to consult with a trusted HCP, who may or may not have experience with AT. By combining factors such as money, expected usefulness, and safety aspects, a decision can be reached to purchase AT. If AT incorporates therapeutic principles and can be used pleasantly in a time-efficient and safe manner, chances of acceptance increase. Time efficiency can be increased by usability factors such as setup time, clear and understandable instructions for use, easy donning or doffing, and adjustability. Features such as monitoring fatigue and detecting wrongly executed movements can contribute to safety. Depending on the use context, either at home for ADL purposes or for rehabilitation at a clinic, the importance of each factor may vary.
Due to this interdependency and a lack of weights attributed to the factors in the included studies, a ranking of most important themes could not be established within this review. Therefore, the current framework should be supplemented by future research evaluating the importance of the factors, while also considering differences in use contexts, such as clinical or domestic application of AT.
Search strategy.
activities of daily living
assistive technology
Critical Appraisal Skills Program
health care professional
International Classification of Functioning, Disability and Health
user-centered design
A part of this study has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No 644000. This result reflects only the author’s view and the European Commission is not responsible for any use of the information in this result. The authors would like to thank C Engbers and L Schaake for their contribution.
ALvO, LCS, and GBPL conducted the literature search. ALvO and LCS drafted the manuscript. GBPL, JHB, PHV, and JSR reviewed and edited the manuscript and supervised the process in the roles of doctoral supervisor and promotor. All authors approved the final version of the manuscript.
None declared.