RESEARCH ARTICLE
Upper Extremity Rehabilitation Equipment for Stroke Patients in Taiwan: Usage Problems and Improvement Needs Lan-Ling Huang1, Chang-Franw Lee2, Ching-Lin Hsieh3 & Mei-Hsiang Chen4* 1
Graduate School of Design, National Yunlin University of Science and Technology, Douliou, Taiwan
2
Department and Graduate School of Industrial Design, National Yunlin University of Science and Technology, Douliou, Taiwan
3
School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
4
School of Occupational Therapy, Chung Shan Medical University/Chung Shan Medical University Hospital, Taichung, Taiwan
Abstract The purpose of this study was to survey occupational therapists for the usage problems and for their improvement needs for upper extremity rehabilitation equipment (UERE). A questionnaire was given to experienced occupational therapists from 113 hospitals that provide occupational therapy services with three or more professional full-time therapists. A total of 48 hospitals sent back questionnaires, and 184 valid questionnaires were received. Most of the UERE had two major problems: The base of the equipment was unstable, and the equipment was uninteresting to use. The therapists reported that three major needs for design improvement in the UERE were adjustability of functions, exchangeability of components and recording of movement data. Some therapists had suggestions for designing new types of UERE, such as manual dexterity training equipment, activities of daily living oriented equipment, sensory re-education equipment, arm supination and pronation training equipment, and wrist extension training equipment. These findings reveal the genuine user needs of upper extremity devices and provide useful applications to the development and re-design of these devices. However, obtaining opinions primarily from experienced occupational therapists may pose a methodological limitation of this study. In future research, it is advised to include patients’ opinions and also investigate whether a clinician’s years of experience would affect his or her viewpoint of usage problems and improvement needs of the UERE. Copyright © 2013 John Wiley & Sons, Ltd. Received 18 November 2012; Revised 12 September 2013; Accepted 12 September 2013 Keywords physical disabilities occupational therapy; upper extremity equipment; usage problems of therapeutic equipment; stroke *Correspondence Mei-Hsiang Chen, School of Occupational Therapy, Chung Shan Medical University/Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Rd., Taichung City 40201, Taiwan. †
Email: [email protected]
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1360
Introduction Up to 85% of stroke patients experience hemiparesis immediately after stroke (Saposnik et al., 2010). Between 55% and 75% of survivors continue to experience motor deficits associated with diminished quality of life Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
(Saposnik et al., 2010). The upper extremities play an important role in daily tasks; therefore, upper extremity recovery is one of the primary goals of stroke rehabilitation. Upper extremity rehabilitation equipment (UERE) is usually used for training the proximal upper extremity movement functions (Lee et al., 2010). They are 205
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essential tools in the occupational therapy (OT) practice and are frequently used in most of Taiwan’s OT clinics. Their individual strengths and weaknesses may affect treatment effectiveness and safety for the patient. Therefore, UERE must be designed with users in mind. Such products that truly fit the users can increase user acceptance (Jacobs, 2008). However, very few researchers have examined the user needs of clinical rehabilitation equipment (Martin et al., 2008; Lee et al., 2010). It is necessary and important for researchers to investigate how well the existing rehabilitation equipment meets the needs of their users and how they can be improved, if necessary, to be more user friendly. Therefore, the objective of this study was to probe the usage problems and improvement needs of the existing UERE used by occupational therapists for patients with stroke at hospitals in Taiwan. It is hoped that the findings of this study could be used to improve existing UERE to meet the practical needs of practitioners providing treatment and quality care.
Methods Subjects The target sample of this study was therapists working in OT departments of hospitals at the time of survey. The surveyed hospitals were taken from the member list of the website of the Occupational Therapists Union of the Republic of China, a national organization of the occupational therapists in Taiwan. One hundred and thirteen hospitals having OT units with three or more full-time therapists were selected and surveyed. Procedures The researchers mailed the questionnaires to one therapist at each selected hospital with an OT department, and then he or she gave the questionnaires to other occupational therapists to fill in. Enclosed with the questionnaires were a pre-addressed stamped envelope and a questionnaire description. The questionnaire description included the purpose of the study, the definition of the surveyed items, a description of the fill-in questionnaire and the deadline for returning the questionnaire to the researchers. The therapists were asked to check the appropriate items according to their personal experiences and opinions. 206
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Measures A questionnaire was developed to survey the usage problems and improvement needs of the existing UERE used in Taiwan hospitals. The questions related to each piece of equipment in the questionnaire were defined on the basis of the results of the preliminary observations of equipment usage and interviews with therapists about the usage patterns of the equipment. Ten clinical therapists who worked in 10 hospitals were interviewed in-depth about problems and needs of the existing UERE. By observation in the field without participation, the researchers observed patients undergoing therapeutic activities in clinical settings. Recordings of the equipment actually used in such settings were kept. The preliminary study results of observations in clinical settings revealed a total of eight pieces of equipment (Table I) that were commonly used in the 10 hospitals for OT (Lee et al., 2010). Therefore, in this questionnaire, the eight pieces of equipment were used as the main objects for the survey. The interview with 10 therapists revealed that some usage problems exist in the UERE, such as problems with base stability, adjustability and durability. Referring to these types of problems, the questionnaire of this study was thus structured. The core purpose of the questionnaire was not only to verify the existence of the usage problems but also to evaluate the significance of them and the preference to deal with them. In addition, opinions about design improvement needs were also solicited. The questionnaire was pilot tested with five occupational therapists, modified and then finalized to ensure that the questions for each UERE were easy to understand for therapists. The questionnaire was written in Chinese. It consisted mainly of four parts: therapist personal profile, questions about usage problems, improvement needs of the eight different types of UERE and suggestions for new designs for UERE (definition of questions and needs are shown in the Appendix). Each therapist was asked two kinds of questions about the equipment: 1) usage problems and 2) improvement needs. The usage problems and adding new design for UERE items were listed on a 5-point Likert-type scale with 1 signifying “strongly disagree” and 5 being “strongly agree”. A multiple-choice checklist concerning features needed for improvement in the new design was also provided. Furthermore, the therapists were also asked to provide additional information not mentioned in the questionnaire. Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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Table 1. The eight pieces of equipment commonly used in 10 hospitals and also widely used for OT in Taiwan
D1. Exercise arm skate
D2. Exercise hand skate
D3. Vertical tower
D4. Horizontal tower
D5. Climbing board and bar
D6. Incline board
D7. Stacking cones
D8. Single curved shoulder arc
Data analysis The collected data were analysed with an SPSS statistical package. The chi-square test or the Fisher’s Exact Test was used for categorical data (number of nonreplying/replying hospitals). For each question on the questionnaire, the frequency, percentage, mean and standard deviation were calculated. For analysis and interpretation purposes, the 5-point Likert scale was treated as an interval scale (Blaikie, 2003; Chiang et al., 2012), and its range (1 to 5) was further divided into five equal intervals of 0.8, as follows: 1.0–1.8 (strongly disagree), 1.8–2.6 (disagree), 2.6–3.4 (neutral), 3.4–4.2 (agree) and 4.2–5.0 (strongly agree). For the results of usage problems of individual pieces of the equipment, the value of 3.4 was used as a cutoff point to determine the significance of the usage problems from the point of view of the respondents. In other words, an average value higher than 3.4 would be used to interpret that therapists thought solving the equipment problems was desirable. Similarly, the
percentage of respondents was used to determine the preference for improvement of the piece of equipment. A higher percentage score signifies a more urgent need for improvement.
Results Two weeks after the questionnaires were sent out, replies started to come back and continued being returned for about 3 months. A total of 48 hospitals sent back questionnaires (a response rate of 42%, out of 113 hospitals), and 184 valid questionnaires were received (a response rate of 35%, out of 530 questionnaires). Analysis of the number of non-replying/replying hospitals (Table II) showed no significant bias in terms of hospital type (public/private, χ 2(1, 113) = 1.773, p = 0.183), rehabilitation unit sizes (large/medium/small, χ 2(2, 113) = 0.535, p = 0.765) and location (north/centre/ south/east, χ 2(3, 113) = 1.297, p = 0.730). Analysis of the returned questionnaires showed the respondents
Table 2. Numbers of surveyed hospitals categorized by non-replying/replying hospitals Number of hospitals that did not reply questionnaires (n = 65) a
Hospital type
Size
Number of hospitals that replied to questionnaires (n = 48) Sizea
Hospital type
Locations
Public
Private
Large
Medium
Small
Public
Private
Large
Medium
Small
North Centre South East Total (n) Total (%)
9 3 5 1 18 28
19 15 13 0 47 72
1 0 2 0 3 5
12 5 5 1 23 35
15 13 11 0 39 60
8 6 5 0 19 40
11 9 7 2 29 60
0 1 0 0 1 2
11 5 3 0 19 40
8 9 9 2 28 58
a
Refers to the number of occupational therapists in the rehabilitation unit of the hospital: large (>11 therapists), medium (6–10 therapists) and
small (1–5 therapists).
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consisting of 68 men (37%) and 116 women (63%), with an average age of 31.4 years (SD: 6.7) and work experience of 7.2 years (SD: 5.9). No more than 5% of the 184 occupational therapists had no experience using the equipment listed in the questionnaire: exercise arm skate (seven therapists), exercise hand skate (two therapists), horizontal tower (three therapists), climbing board and bar (three therapists), incline board (two therapists) and single curved shoulder arc (two therapists).
Usage problems of UERE The usage problems can be classified into two categories: 1) common usage problems and 2) special usage problems. A common usage problem may exist in almost all relevant pieces of the equipment, unless it
is inapplicable to the design feature or usage feature of the piece of equipment. For example, the exercise arm skate (D1) does not have a base and is not meant for height operation; hence, it is not relevant to the usage problems of “height not adjustable” and “base unstable”. So is the case of D2. A specific usage problem, however, existed in only a few specific pieces of the equipment. Table III shows the evaluation results of the usage problems. The number of items surveyed to each of the eight components regarding usage problems varies from four to five. This is because not all problems could apply to all components. In other words, each piece of equipment was surveyed with its applicable usage problem items only. Each mean score in Table III is based on an individual item with respect to the piece of equipment surveyed. Further elaboration of the results follows.
Table 3. Evaluation results of usage problems of the UERE in the questionnaire by the therapists Rehabilitation equipment, valid respondents (n) D1 (177) D2 (182) D3 (184) D4 (181) D5 (181) D6 (182) D7 (184) D8 (183) Overall mean (SD) Questions Common usage problems a) Uninteresting b) Easily damaged
3.6 (0.9) 2.9 (1.1)
3.5 (0.8) 2.8 (1.1)
3.0 (1.2) 3.7 (0.8) 2.6 (0.9)
3.2 (1.1) 3.5 (1.0) 3.5 (0.9)
c) Height not adjustablea d) Base unstablea Specific usage problemsb e) Additional sandbag f) Inconvenient installation g) Straps easily loosen
2.9 (0.7) 2.6 (1.1) 2.8 (0.9) 3.6 (0.9)
3.2 (0.8) 2.3 (1.0) 2.8 (1.0) 3.5 (1.0)
3.2 (0.8) 2.8 (1.1) 2.4 (0.9) 2.8 (1.2)
3.2 (0.7) 3.1 (1.2) 2.6 (0.9) 2.3 (1.0)
3.0 (0.9) 3.6 (1.1) 2.2 (0.8) 3.1 (1.1)
3.1 (0.8) 2.3 (1.1) 3.7 (1.0) 4.0 (1.1)
3.2 (0.7) 2.7 (0.8) 2.7 (0.8) 3.3 (0.8)
3.6 (1.0)
3.3 (1.1) 3.6 (1.0) 3.4 (1.0) 3.5 (0.9)
3.3 (1.2)
h) No difficulty level adjustment
Adding new design for UERE i) Integration design (n = 172)
3.8 (1.0) 4.0 (0.8)
j) New function design (n = 135)
a
Equipment D1 and D2 do not apply to these two common usage problems because of their usage features.
b
Usage problems related to specific equipment only.
The blank cells in Table III indicate that the usage problem is not applicable to that corresponding equipment. D1 = exercise arm skate; D2 = exercise hand skate; D3 = vertical tower; D4 = horizontal tower; D5 = climbing board and bar; D6 = incline board; D7 = stacking cones; D8 = single curved shoulder arc.
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Common usage problems of UERE The most significant problems with the existing UERE were the following: 1) base unstable (especially for vertical tower, mean 3.6; horizontal tower, mean 3.5; and single curved shoulder arc, mean 4.0) and 2) uninteresting (especially for exercise arm skate, mean 3.6; and exercise hand skate, mean 3.5) (Table III).
Special usage problems of UERE The primary special usage problems with the existing eight UERE (Table III) were the following: 1) inconvenient installation (especially for exercise arm skate, mean 3.7; and exercise hand skate, mean 3.5), 2) straps easily loosen (especially for exercise hand skate, mean 3.5) and 3) no difficulty level adjustment (especially for single curved shoulder arc, mean 3.6).
Improvement needs of the existing UERE The bottom row of Table IV shows the percentage results of improvement needs of individual types of equipment. A higher value signifies a more urgent need for improvement. For example, the exercise arm skate, the exercise hand skate and the single curved shoulder arc, with percentages of 51%, 50% and 46%, respectively, were the ones with the greatest need for improvement among the eight surveyed types of equipment. The right-most column of Table IV shows the percentage of therapists who suggested that any new design of the equipment should include some of the following features. The top three features with the highest percentages were the following: 1) adjustability in function (58%), 2) interchangeable components (52%) and 3) recording of movement data (45%).
These features, therefore, have higher priorities to be implemented. Some illustrations of these points follow: 1. Adjustability in function: For example, the single curved shoulder arc installed on the desktop may sometimes be too high for some patients to reach from a seated position. An adjustable design in the curvature and height would easily solve this problem. Six of the eight surveyed types of equipment (single curved shoulder arc, exercise hand skate, exercise arm skate, horizontal tower, incline board and vertical tower) were shown have high percentages (≧50%) in design improvement needs. 2. Interchangeable components: Items of different shapes, sizes, weights and so on are needed in order to meet the therapeutic purposes. Four of the types of equipment (vertical tower, horizontal tower, stacking cones and single curved shoulder arc) had high percentages in this improvement need, suggesting the need for interchangeable components. 3. Recording of movement data in each treatment: three types of equipment (exercise arm skate, exercise hand skate and incline board) of the surveyed types of equipment had high percentages in this improvement need.
Adding new design features of UERE Table III shows that the respondents supporting integration of design agreed (mean 3.8) to integrate variations of the current clinical use of UERE into a few modular types, which could be used in various combinations. The respondents agreed (mean 4.0) that new functional designs are recommended for new types of UERE. Thirty six of the 135 respondents agreed that the proposed types
Table 4. Improvement needs of UERE based on percentages of therapists’ responses for each feature Rehabilitation equipment Features needed in new designs (%)
D1
D2
D3
D4
D5
D6
D7
D8
Mean
a) Interchangeable components b) Adjustable grips c) Durable material d) Adjustable function e) Recording of movement data Mean
44 42 43 66 61 51
46 41 42 67 56 50
70 28 28 55 35 43
59 29 21 60 40 42
38 23 32 48 46 37
48 28 38 57 54 45
57 38 51 39 33 44
56 46 20 69 37 46
52 34 34 58 45 45
D1, exercise arm skate; D2, exercise hand skate; D3, vertical tower; D4, horizontal tower; D5, climbing board and bar; D6, incline board; D7, stacking cones; D8, single curved shoulder arc.
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of UERE should include the following functional designs: 1) manual dexterity training equipment (18 of 36 therapists), 2) activities of daily living (ADL)-oriented equipment (five of 36 therapists), 3) sensory re-education equipment (five of 36 therapists), 4) arm supination and pronation training equipment (five of 36 therapists) and 5) wrist extension training equipment (four of 36 therapists).
Discussion Common usage problems of the existing UERE From the usage problem results of the eight types of equipment, most equipment was reported to have two most significant problems: base instability and uninteresting. For the base instability problem, therapists reported that the problem occurred frequently in using these pieces of equipment, and this problem had yet to be resolved. The vertical tower, horizontal tower and single curved shoulder arc (Table I), for example, were unstable and easy to topple when patients exerted excessive force. Unstable pieces of equipment, when they topple, would increase risks for patients as well as damage the equipment. Therapists working in a stroke rehabilitation setting may add weights, anchors or clamps when using the UERE. That is, therapists must adjust the UERE to meet the contextual and safety demands. Because modification of the UERE is part of OT practice, in-service training or workshops focused on modification of the UERE are highly recommended. Our findings may be useful to improve the design of UERE. A possible reason for the base instability problem is that some of the bases of the equipment are made of wood, although light in weight but unable to sustain heavy forces during operation. In addition, the surveyed therapists reported that a narrow base device usually makes its utility more difficult. A possible solution to this problem may be designing the base to be adaptable to fit a vast array of settings where the equipment can be employed. For example, the device may be fixed on the table with a clamping component with a flexible connector adaptable to various devices. Another possibility is to design a standalone base with lockable castors. The base should also have a flexible connector adaptable to various devices. Moreover, it is noted that a narrow base conceptually makes the flexibility of the device useful for multiple situations. For example, smaller equipment is lighter, thus allowing clinicians to take it bedside or 210
into a home setting. Such an advantage should be kept for any new UERE. Furthermore, the advent of interaction technology may offer another potential solution to the weight problem of therapeutic equipment by replacing the physical equipment with virtual interaction equipment. In other words, commonly available digital gaming systems may have a role to play in this situation, creating therapeutic alternatives that are effective and inexpensive, and result in a decrease in hospital expenses over a lifetime (Flynn et al., 2007). Compared with the traditional rehabilitation method, the digital gaming system has several advantages, which include easily set up by individuals, easily adjustable, capable of measurements and able to provide feedback, and the inclusion of stimulus features (Kheng, 2009).
Uninteresting Therapists reported that patients usually felt bored during the treatment process. Patients at each session of therapy take about 15–20 min in repeated use of the equipment, which are common in Taiwan because a therapist usually has to take care of two to three patients at a session. A therapist has to try to motivate patients, for example, by embedding meaningful occupations with the UERE. The outcomes of OT would be best when the tasks employed for patients are meaningful to patients. Many UERE are employed for the purpose of preparing the body for future integrated work. For example, many clinicians begin OT for patients with stroke with a UERE and range of motion therapy prior to engaging the patient and move on to functional reaching tasks. These prior or preparatory activities are part of the treatment process. However, a skilled therapist knows that these tasks are not the end goal of therapy. These tasks are required components and are often only the short-term goals. These short-term goals contribute to longer-term goals like being able to independently do upper-body dressing. A key challenge for a clinician is to motivate a patient through/during the more routine preparatory activities in anticipation of future meaningful occupations. The meaning component in OT is how a therapist utilizes an individual success with the UERE and clearly ties these successes to future purposeful activities. Additionally, a better designed piece of equipment with variable options to choose and fun to use may also be helpful for therapists to plan the therapy activities Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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with interaction and feedback. These therapy activities may raise clients’ motivation to participate in the activities. With the increase of clients’ motivation, both patients’ levels of participation in therapy activities and the therapeutic effectiveness might also increase as a result. Adding new design features for UERE The results on adding new design features to UERE showed that therapists agreed with an integrated design of equipment, which was similar in structure and usage pattern, and they also suggested new function designs for UERE. For integrated design, it would be beneficial to integrate the UERE in current clinical use into a few modular types. There are two possible reasons for integrating the UERE as follows: 1) Many UERE are designed to have the same basic function (e.g. usage pattern and whole structure of the equipment) but are limited to certain functions by size or shape. For example, exercise arm skate and exercise hand skate have the same overall structure and usage pattern, differing only in size. Although this provides a more diverse equipment range, the use of two pieces of equipment raises issues with storage and management. 2) At present, most OT departments face space limitations and budget restraints. Therefore, integration of designs is necessary to save space and costs by integrating equipment with high homogeneity into one product. This suggestion, if applied in equipment development, would reduce equipment development costs in the main mould cost. In addition, in the use of the equipment, such a design could resolve problems of movement and storage of equipment for therapists; patients could remain in a fixed position while using a variety of rehabilitation equipment; and finally, equipment would be easier to manage for therapists or medical equipment managers. New function design Therapists thought that the functions of the existing UERE were insufficient to meet the demands for treatment; therefore, additional UERE were suggested. The therapists’ primary suggestions for designing new equipment were as follows: manual dexterity training equipment, ADL-oriented training equipment, sensory re-education equipment, arm supination and pronation training equipment, and wrist extension training equipment. Because the existing UERE are mainly for motor training of the extension and bending movements Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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of the arm, there is a lack of equipment for other treatment purposes (for example, manual dexterity training equipment, ADL-oriented training equipment, sensory re-education equipment and wrist extension training equipment). Our findings echo those of the previous studies (Bode et al., 2004; Richards et al., 2005) that occupational therapists spent almost half of the therapy time providing interventions that addressed performance skills or body structure, and function impairments, such as motor rehabilitation, cognitive retraining or therapeutic equipment. In addition, Latham et al. (2006) reported that during stroke rehabilitation, about 40% of the OT provided directly targeted life activities (i.e. ADL and instrumental ADL). As upper extremity function improved, ADL training may have progressed from compensatory training to a more remedial approach in which emerging upper extremity motor skills were incorporated into ADL (Richards et al., 2005). Therefore, this points to a need for such equipment in clinical treatment and also provides suggestions on further development of UERE.
Needs in the new design of UERE From the survey results, the three most needed features requiring new equipment design are the following: adjustability in function, interchangeable components and recording of movement data. For adjustability in function, the functions and operational parts of current UERE are fixed and cannot be adjusted to meet the specific needs of different users. In addition, UERE are commonly used with ordinary tables and chairs, not furniture specially designed for use in therapeutic settings. For example, the height and angle of a table surface cannot be adjusted for use with a specific therapeutic UERE or to compensate for the user’s stature, and normal chairs cannot be adjusted to match the patient’s posture or fixed to stabilize the patient’s posture. Because these pieces of furniture are not adjustable, users often experience discomfort while operating the UERE. Therefore, if the functions of a piece of equipment are adjustable according to the patient’s physical condition or needs, it will help patients to implement the therapy activities and help the therapist to custom design different treatment activities. In order to cater to different user operational situations (standing/sitting/wheelchair, etc.) for different rehabilitation UERE, the equipment should be designed with adjustability in function. The basic functions should 211
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include adjustability for the height of the equipment and position of the operation object. These must be designed in a way that facilitates operation of the operation objects and adjustment of the position of the operation objects for therapy activities, and the height of the equipment should be adjustable to be compatible with natural human modes of operation. Interchangeable components We found that interchangeable components are also desirable in design improvement. Many of the current clinical UERE do not have interchangeable operation components and cannot meet the treatment needs of different stroke patients. Therapists noted that when the equipment cannot meet the need for treatment, they must spend much time looking for an alternative commercial, off-the-shelf product to replace the operation components of the equipment. While these alternative products can be used to solve the problem, implementation of the new component may create other problems. For example, the single curved shoulder arc, which uses thin slices of wood and is used to treat problems with distal upper extremity motor impairment, cannot be pinched in a way to operate well. As a result, the therapist needs to wrap the wood with sponges so that these patients will then be able to grip the tube to move the thin slices of wood. However, this is only a temporary solution. Therefore, a better solution would require that the operation components are interchangeable for the users (therapists and patients). Recording of movement data The third major need for design improvement in the UERE was recording of movement data. Lee et al. (2010) found that some therapists tend to use selfdesigned forms for recording treatment data, such as the accomplishment time and the number of operations each time, and use these data as a reference for the expected achievement targets of the patient in the next treatment. Another study conducted by these researchers, on “involving digital games in rehabilitation therapy”, found that some patients would remember personal high scores for each game by himself or herself and expect to break the scores in following sessions (Huang et al., 2012). In view of this point, recording of movement data is indeed needed, for it could provide meaningful and valuable feedback for clinical treatment. Therefore, if this need is implemented, 212
therapists and patients will be provided with useful information to understand their treatment progress and to map out short-term to long-term plans with foreseeable goals for both parties. The further development and investigation of UERE This study reports that usage problems and design improvement needs do exist in UERE. To achieve greater clarity, it also prioritizes the points where design expertise should be focused in the further development of UERE. A similar finding was also reported in Kersten et al. (2000), where equipment needs were identified as one of the seven categories of unmet needs for rehabilitation services. Some studies have also shown that prioritizing problems is a first step to problem solving, a process that has been found helpful in rehabilitation (McGrath and Adams, 1999; Grant et al., 2002; Mackenzie et al., 2007). In view of the continuing technological advances, development and design of new and sufficient UERE for use in rehabilitation are even more essential. In order to improve the quality and effectiveness of OT, we should pursue progress in treatment methods and also advances in therapeutic equipment. To the best our knowledge, the UERE surveyed in this study are generally lacking empirical evidence to support their effectiveness. In addition, as aforementioned, the patients felt bored when using the UERE, and new designs are needed for improving the UERE’s utility. These observations indicate a strong need for examining the effectiveness of the current UERE and the revised UERE, if any in the future. Limitations Though much effort had been exerted to maintain the validity of the questionnaire, there remains one point of concern regarding the results of this survey, hence the limitation of this study. Furthermore, because this survey aimed to verify the usage problems and their improvement needs for UERE, the clinicians’ years of experience were not treated as a variable in this survey. In order to fully understand whether a clinician’s years of experience affects the viewpoint of usage problems and improvement needs, further studies are needed. In addition, the users of the UERE include not only the therapists but also the patients. However, the data in this study were obtained only from Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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experienced occupational therapists. Although expert therapists with much clinical experience and expertise on rehabilitation equipment are able to respond to the questions regarding the current situation and needs, it would be better if the views of patients were also further surveyed. Such an inclusion would be desirable in another research project so as to justify and supplement our findings. A further limitation is that information on whether a clinician selected one piece of equipment over the others was not surveyed. Hence, the clinicians’ preferences on the UERE were not available.
Conclusions This study concludes that therapists indicated that a need did exist for improvements in the current UERE in Taiwan. The major needs for design improvement in the UERE include the following: better stability of the equipment, higher interest in use, adjustability of functions, interchangeability of components and recording of patient movement data. In addition, therapists also suggested that there was need to include new functional design in the UERE: manual dexterity training equipment, ADL-oriented equipment, sensory re-education equipment, arm supination and pronation training equipment, and wrist extension training equipment. These needs and recommendations proposed by experienced occupational therapists should be useful for other clinical practitioners, rehabilitation equipment designers and manufacturers, and other experts in the development of rehabilitation equipment. The use of digital interfaces such as gaming devices for upper extremity therapy would be a much desired direction in equipment design. It is hoped that the information gained from this study can be used to bring the equipment more in line with the goals and true needs of treatment and hence increase the efficiency and safety of upper extremity rehabilitation.
Acknowledgement This study was supported by the National Science Council of the Republic of China with grant no. NSC99-2221-E-040-009. REFERENCES Blaikie N (2003). Analyzing Quantitative Data. London: Sage. Bode RK, Heinemann AW, Semik P, Mallinson T (2004). Patterns of therapy activities across length of stay and impairment levels: Peering inside the “black box” of Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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inpatient stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 85(12): 1901–1908. Chiang HYA, Pang CH, Li WS, Shih YN, Su CT (2012). An investigation of the satisfaction and perception of fieldwork experiences among occupational therapy students. Hong Kong Journal of Occupational Therapy 22(1): 9–16. Flynn S, Palma P, Bender, A (2007). Feasibility of using the Sony PlayStation 2 gaming platform for an individual poststroke a case report. Journal of Neurologic Physical Therapy 31(4): 180–189. Grant JS, Elliott TR, Weaver M, Bartolucci AA, Giger JN (2002). Telephone intervention with family caregivers of stroke survivors after rehabilitation. Stroke 33: 2060–2065. Huang LL, Lee CF, Chen MH (2012). Usability assessment of off-the-shelf digital game equipments for stroke rehabilitation in Taiwan: usage problems and improvement needs for users. Paper presented at the meeting of the 4th International Conference for Universal Design, Fukuoka, Japan. Jacobs K (2008). Ergonomics for Therapists. (3rd edn). United States: Mosby Elsevier. Kersten P, McLellan DL, Gross-Paju K, Grigoriadis N, Bencivenga R, Beneton C, Charlier M, Keteiaer P, Thompson AJ (2000). A questionnaire assessment of unmet needs for rehabilitation services and resources for people with multiple sclerosis: results of a pilot survey in five European countries. Disability and Rehabilitation 14: 42–49. Kheng TY (2009). Rehabilitation Engineering. India: In-Tech. Latham NK, Jette DU, Coster W, Richards L, Smout RJ, James RA, Gassaway J, Horn SD (2006). Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals. The American Journal of Occupational Therapy 60(4): 369–378. Lee CF, Huang LL, Chen MH (2010). An investigation of the upper extremity rehabilitation equipments for stroke patients. Journal of Science and Technology— Humanity and Sociology 19(2): 103–114. Mackenzie A, Perry L, Lockhart E, Cottee M, Cloud G, Mann H (2007). Family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring. Disability and Rehabilitation 30(29): 111–121. Martin JL, Norris BJ, Murphy E, Crowe JA (2008). Medical equipment development: the challenge for ergonomics. Applied Ergonomics 39: 271–283. McGrath JR, Adams L (1999). Patient-centered goal planning a systematic psychological theory? Top Stroke Rehabilitation 6(2): 43–50. Richards LG, Latham NK, Jette DU, Rosenberg L, Smout RJ, DeJong G (2005). Characterizing 213
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occupational therapy practice in stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 86(12): 51–60. Saposnik G, Teasell R, Mamdani M, Hall J, McIlroy W, Cheung D, Thorpe KE, Cohen LG, Bayley M,
the Stroke Outcome Research Canada Working Group (2010). Effectiveness of virtual reality using WII gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle. Stroke 41: 1477–1484.
Appendices The questions were defined in the questionnaire. Questions Usage problems of UERE Common usage problems
a) Uninteresting b) Easily damaged
c) Height not adjustable d) Base unstable Specific usage problems
e) Additional sandbag f) Inconvenient installation g) Straps easily loosen h) No difficulty level adjustment
Adding new design of UERE
i) Integration of design j) New function design
Improvement needs of UERE
k) Interchangeable components l) Grips adjustable m) Durable material n) Adjustable in function o) Record movement data in each treatment
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Definition Patients usually feel a sense of boredom during the therapy process using these types of equipment. These equipment are easily damaged with unbalanced operation from the patients who, because of lack of control of their body parts, involuntarily exert excessive force or undue action in the operation. The equipment cannot be adjusted to fit patient’s operating height: This would cause inconvenience during the treatment. The equipment is not stable to operate because they do not have a firm base. Equipment with similar functions could be combined and integrated into a single piece of equipment in a new design. Patients cannot easily install equipment with their hands. When using the equipment for an activity, the installed straps easily loosen, causing instability. Operational components of the equipment cannot be adjusted, so some patients are unable to operate it. Equipment with similar functions could be combined and integrated into a single piece of equipment with a new design. It is desirable to add equipment with additional functions in a new design: If you agree, please specify. Interchangeable operable components and operation patterns (such as shapes, materials and weight). Easy to fit hand in different postures. Easy to clean and resistant to abrasion. Adjustable means to provide adaptable features to meet therapeutic needs of the patient’s physical condition. Registration of the patient’s action data would provide the therapist a better understanding of the patient after each treatment, so that he or she can evaluate the effectiveness and efficiency of the treatment.
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Upper Extremity Rehabilitation Equipment for Stroke Patients in Taiwan: Usage Problems and Improvement Needs Lan-Ling Huang1, Chang-Franw Lee2, Ching-Lin Hsieh3 & Mei-Hsiang Chen4* 1
Graduate School of Design, National Yunlin University of Science and Technology, Douliou, Taiwan
2
Department and Graduate School of Industrial Design, National Yunlin University of Science and Technology, Douliou, Taiwan
3
School of Occupational Therapy, College of Medicine, National Taiwan University, Taipei, Taiwan
4
School of Occupational Therapy, Chung Shan Medical University/Chung Shan Medical University Hospital, Taichung, Taiwan
Abstract The purpose of this study was to survey occupational therapists for the usage problems and for their improvement needs for upper extremity rehabilitation equipment (UERE). A questionnaire was given to experienced occupational therapists from 113 hospitals that provide occupational therapy services with three or more professional full-time therapists. A total of 48 hospitals sent back questionnaires, and 184 valid questionnaires were received. Most of the UERE had two major problems: The base of the equipment was unstable, and the equipment was uninteresting to use. The therapists reported that three major needs for design improvement in the UERE were adjustability of functions, exchangeability of components and recording of movement data. Some therapists had suggestions for designing new types of UERE, such as manual dexterity training equipment, activities of daily living oriented equipment, sensory re-education equipment, arm supination and pronation training equipment, and wrist extension training equipment. These findings reveal the genuine user needs of upper extremity devices and provide useful applications to the development and re-design of these devices. However, obtaining opinions primarily from experienced occupational therapists may pose a methodological limitation of this study. In future research, it is advised to include patients’ opinions and also investigate whether a clinician’s years of experience would affect his or her viewpoint of usage problems and improvement needs of the UERE. Copyright © 2013 John Wiley & Sons, Ltd. Received 18 November 2012; Revised 12 September 2013; Accepted 12 September 2013 Keywords physical disabilities occupational therapy; upper extremity equipment; usage problems of therapeutic equipment; stroke *Correspondence Mei-Hsiang Chen, School of Occupational Therapy, Chung Shan Medical University/Chung Shan Medical University Hospital, No. 110, Sec. 1, Jianguo N. Rd., Taichung City 40201, Taiwan. †
Email: [email protected]
Published online in Wiley Online Library (wileyonlinelibrary.com) DOI: 10.1002/oti.1360
Introduction Up to 85% of stroke patients experience hemiparesis immediately after stroke (Saposnik et al., 2010). Between 55% and 75% of survivors continue to experience motor deficits associated with diminished quality of life Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
(Saposnik et al., 2010). The upper extremities play an important role in daily tasks; therefore, upper extremity recovery is one of the primary goals of stroke rehabilitation. Upper extremity rehabilitation equipment (UERE) is usually used for training the proximal upper extremity movement functions (Lee et al., 2010). They are 205
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essential tools in the occupational therapy (OT) practice and are frequently used in most of Taiwan’s OT clinics. Their individual strengths and weaknesses may affect treatment effectiveness and safety for the patient. Therefore, UERE must be designed with users in mind. Such products that truly fit the users can increase user acceptance (Jacobs, 2008). However, very few researchers have examined the user needs of clinical rehabilitation equipment (Martin et al., 2008; Lee et al., 2010). It is necessary and important for researchers to investigate how well the existing rehabilitation equipment meets the needs of their users and how they can be improved, if necessary, to be more user friendly. Therefore, the objective of this study was to probe the usage problems and improvement needs of the existing UERE used by occupational therapists for patients with stroke at hospitals in Taiwan. It is hoped that the findings of this study could be used to improve existing UERE to meet the practical needs of practitioners providing treatment and quality care.
Methods Subjects The target sample of this study was therapists working in OT departments of hospitals at the time of survey. The surveyed hospitals were taken from the member list of the website of the Occupational Therapists Union of the Republic of China, a national organization of the occupational therapists in Taiwan. One hundred and thirteen hospitals having OT units with three or more full-time therapists were selected and surveyed. Procedures The researchers mailed the questionnaires to one therapist at each selected hospital with an OT department, and then he or she gave the questionnaires to other occupational therapists to fill in. Enclosed with the questionnaires were a pre-addressed stamped envelope and a questionnaire description. The questionnaire description included the purpose of the study, the definition of the surveyed items, a description of the fill-in questionnaire and the deadline for returning the questionnaire to the researchers. The therapists were asked to check the appropriate items according to their personal experiences and opinions. 206
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Measures A questionnaire was developed to survey the usage problems and improvement needs of the existing UERE used in Taiwan hospitals. The questions related to each piece of equipment in the questionnaire were defined on the basis of the results of the preliminary observations of equipment usage and interviews with therapists about the usage patterns of the equipment. Ten clinical therapists who worked in 10 hospitals were interviewed in-depth about problems and needs of the existing UERE. By observation in the field without participation, the researchers observed patients undergoing therapeutic activities in clinical settings. Recordings of the equipment actually used in such settings were kept. The preliminary study results of observations in clinical settings revealed a total of eight pieces of equipment (Table I) that were commonly used in the 10 hospitals for OT (Lee et al., 2010). Therefore, in this questionnaire, the eight pieces of equipment were used as the main objects for the survey. The interview with 10 therapists revealed that some usage problems exist in the UERE, such as problems with base stability, adjustability and durability. Referring to these types of problems, the questionnaire of this study was thus structured. The core purpose of the questionnaire was not only to verify the existence of the usage problems but also to evaluate the significance of them and the preference to deal with them. In addition, opinions about design improvement needs were also solicited. The questionnaire was pilot tested with five occupational therapists, modified and then finalized to ensure that the questions for each UERE were easy to understand for therapists. The questionnaire was written in Chinese. It consisted mainly of four parts: therapist personal profile, questions about usage problems, improvement needs of the eight different types of UERE and suggestions for new designs for UERE (definition of questions and needs are shown in the Appendix). Each therapist was asked two kinds of questions about the equipment: 1) usage problems and 2) improvement needs. The usage problems and adding new design for UERE items were listed on a 5-point Likert-type scale with 1 signifying “strongly disagree” and 5 being “strongly agree”. A multiple-choice checklist concerning features needed for improvement in the new design was also provided. Furthermore, the therapists were also asked to provide additional information not mentioned in the questionnaire. Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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Table 1. The eight pieces of equipment commonly used in 10 hospitals and also widely used for OT in Taiwan
D1. Exercise arm skate
D2. Exercise hand skate
D3. Vertical tower
D4. Horizontal tower
D5. Climbing board and bar
D6. Incline board
D7. Stacking cones
D8. Single curved shoulder arc
Data analysis The collected data were analysed with an SPSS statistical package. The chi-square test or the Fisher’s Exact Test was used for categorical data (number of nonreplying/replying hospitals). For each question on the questionnaire, the frequency, percentage, mean and standard deviation were calculated. For analysis and interpretation purposes, the 5-point Likert scale was treated as an interval scale (Blaikie, 2003; Chiang et al., 2012), and its range (1 to 5) was further divided into five equal intervals of 0.8, as follows: 1.0–1.8 (strongly disagree), 1.8–2.6 (disagree), 2.6–3.4 (neutral), 3.4–4.2 (agree) and 4.2–5.0 (strongly agree). For the results of usage problems of individual pieces of the equipment, the value of 3.4 was used as a cutoff point to determine the significance of the usage problems from the point of view of the respondents. In other words, an average value higher than 3.4 would be used to interpret that therapists thought solving the equipment problems was desirable. Similarly, the
percentage of respondents was used to determine the preference for improvement of the piece of equipment. A higher percentage score signifies a more urgent need for improvement.
Results Two weeks after the questionnaires were sent out, replies started to come back and continued being returned for about 3 months. A total of 48 hospitals sent back questionnaires (a response rate of 42%, out of 113 hospitals), and 184 valid questionnaires were received (a response rate of 35%, out of 530 questionnaires). Analysis of the number of non-replying/replying hospitals (Table II) showed no significant bias in terms of hospital type (public/private, χ 2(1, 113) = 1.773, p = 0.183), rehabilitation unit sizes (large/medium/small, χ 2(2, 113) = 0.535, p = 0.765) and location (north/centre/ south/east, χ 2(3, 113) = 1.297, p = 0.730). Analysis of the returned questionnaires showed the respondents
Table 2. Numbers of surveyed hospitals categorized by non-replying/replying hospitals Number of hospitals that did not reply questionnaires (n = 65) a
Hospital type
Size
Number of hospitals that replied to questionnaires (n = 48) Sizea
Hospital type
Locations
Public
Private
Large
Medium
Small
Public
Private
Large
Medium
Small
North Centre South East Total (n) Total (%)
9 3 5 1 18 28
19 15 13 0 47 72
1 0 2 0 3 5
12 5 5 1 23 35
15 13 11 0 39 60
8 6 5 0 19 40
11 9 7 2 29 60
0 1 0 0 1 2
11 5 3 0 19 40
8 9 9 2 28 58
a
Refers to the number of occupational therapists in the rehabilitation unit of the hospital: large (>11 therapists), medium (6–10 therapists) and
small (1–5 therapists).
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consisting of 68 men (37%) and 116 women (63%), with an average age of 31.4 years (SD: 6.7) and work experience of 7.2 years (SD: 5.9). No more than 5% of the 184 occupational therapists had no experience using the equipment listed in the questionnaire: exercise arm skate (seven therapists), exercise hand skate (two therapists), horizontal tower (three therapists), climbing board and bar (three therapists), incline board (two therapists) and single curved shoulder arc (two therapists).
Usage problems of UERE The usage problems can be classified into two categories: 1) common usage problems and 2) special usage problems. A common usage problem may exist in almost all relevant pieces of the equipment, unless it
is inapplicable to the design feature or usage feature of the piece of equipment. For example, the exercise arm skate (D1) does not have a base and is not meant for height operation; hence, it is not relevant to the usage problems of “height not adjustable” and “base unstable”. So is the case of D2. A specific usage problem, however, existed in only a few specific pieces of the equipment. Table III shows the evaluation results of the usage problems. The number of items surveyed to each of the eight components regarding usage problems varies from four to five. This is because not all problems could apply to all components. In other words, each piece of equipment was surveyed with its applicable usage problem items only. Each mean score in Table III is based on an individual item with respect to the piece of equipment surveyed. Further elaboration of the results follows.
Table 3. Evaluation results of usage problems of the UERE in the questionnaire by the therapists Rehabilitation equipment, valid respondents (n) D1 (177) D2 (182) D3 (184) D4 (181) D5 (181) D6 (182) D7 (184) D8 (183) Overall mean (SD) Questions Common usage problems a) Uninteresting b) Easily damaged
3.6 (0.9) 2.9 (1.1)
3.5 (0.8) 2.8 (1.1)
3.0 (1.2) 3.7 (0.8) 2.6 (0.9)
3.2 (1.1) 3.5 (1.0) 3.5 (0.9)
c) Height not adjustablea d) Base unstablea Specific usage problemsb e) Additional sandbag f) Inconvenient installation g) Straps easily loosen
2.9 (0.7) 2.6 (1.1) 2.8 (0.9) 3.6 (0.9)
3.2 (0.8) 2.3 (1.0) 2.8 (1.0) 3.5 (1.0)
3.2 (0.8) 2.8 (1.1) 2.4 (0.9) 2.8 (1.2)
3.2 (0.7) 3.1 (1.2) 2.6 (0.9) 2.3 (1.0)
3.0 (0.9) 3.6 (1.1) 2.2 (0.8) 3.1 (1.1)
3.1 (0.8) 2.3 (1.1) 3.7 (1.0) 4.0 (1.1)
3.2 (0.7) 2.7 (0.8) 2.7 (0.8) 3.3 (0.8)
3.6 (1.0)
3.3 (1.1) 3.6 (1.0) 3.4 (1.0) 3.5 (0.9)
3.3 (1.2)
h) No difficulty level adjustment
Adding new design for UERE i) Integration design (n = 172)
3.8 (1.0) 4.0 (0.8)
j) New function design (n = 135)
a
Equipment D1 and D2 do not apply to these two common usage problems because of their usage features.
b
Usage problems related to specific equipment only.
The blank cells in Table III indicate that the usage problem is not applicable to that corresponding equipment. D1 = exercise arm skate; D2 = exercise hand skate; D3 = vertical tower; D4 = horizontal tower; D5 = climbing board and bar; D6 = incline board; D7 = stacking cones; D8 = single curved shoulder arc.
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Common usage problems of UERE The most significant problems with the existing UERE were the following: 1) base unstable (especially for vertical tower, mean 3.6; horizontal tower, mean 3.5; and single curved shoulder arc, mean 4.0) and 2) uninteresting (especially for exercise arm skate, mean 3.6; and exercise hand skate, mean 3.5) (Table III).
Special usage problems of UERE The primary special usage problems with the existing eight UERE (Table III) were the following: 1) inconvenient installation (especially for exercise arm skate, mean 3.7; and exercise hand skate, mean 3.5), 2) straps easily loosen (especially for exercise hand skate, mean 3.5) and 3) no difficulty level adjustment (especially for single curved shoulder arc, mean 3.6).
Improvement needs of the existing UERE The bottom row of Table IV shows the percentage results of improvement needs of individual types of equipment. A higher value signifies a more urgent need for improvement. For example, the exercise arm skate, the exercise hand skate and the single curved shoulder arc, with percentages of 51%, 50% and 46%, respectively, were the ones with the greatest need for improvement among the eight surveyed types of equipment. The right-most column of Table IV shows the percentage of therapists who suggested that any new design of the equipment should include some of the following features. The top three features with the highest percentages were the following: 1) adjustability in function (58%), 2) interchangeable components (52%) and 3) recording of movement data (45%).
These features, therefore, have higher priorities to be implemented. Some illustrations of these points follow: 1. Adjustability in function: For example, the single curved shoulder arc installed on the desktop may sometimes be too high for some patients to reach from a seated position. An adjustable design in the curvature and height would easily solve this problem. Six of the eight surveyed types of equipment (single curved shoulder arc, exercise hand skate, exercise arm skate, horizontal tower, incline board and vertical tower) were shown have high percentages (≧50%) in design improvement needs. 2. Interchangeable components: Items of different shapes, sizes, weights and so on are needed in order to meet the therapeutic purposes. Four of the types of equipment (vertical tower, horizontal tower, stacking cones and single curved shoulder arc) had high percentages in this improvement need, suggesting the need for interchangeable components. 3. Recording of movement data in each treatment: three types of equipment (exercise arm skate, exercise hand skate and incline board) of the surveyed types of equipment had high percentages in this improvement need.
Adding new design features of UERE Table III shows that the respondents supporting integration of design agreed (mean 3.8) to integrate variations of the current clinical use of UERE into a few modular types, which could be used in various combinations. The respondents agreed (mean 4.0) that new functional designs are recommended for new types of UERE. Thirty six of the 135 respondents agreed that the proposed types
Table 4. Improvement needs of UERE based on percentages of therapists’ responses for each feature Rehabilitation equipment Features needed in new designs (%)
D1
D2
D3
D4
D5
D6
D7
D8
Mean
a) Interchangeable components b) Adjustable grips c) Durable material d) Adjustable function e) Recording of movement data Mean
44 42 43 66 61 51
46 41 42 67 56 50
70 28 28 55 35 43
59 29 21 60 40 42
38 23 32 48 46 37
48 28 38 57 54 45
57 38 51 39 33 44
56 46 20 69 37 46
52 34 34 58 45 45
D1, exercise arm skate; D2, exercise hand skate; D3, vertical tower; D4, horizontal tower; D5, climbing board and bar; D6, incline board; D7, stacking cones; D8, single curved shoulder arc.
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of UERE should include the following functional designs: 1) manual dexterity training equipment (18 of 36 therapists), 2) activities of daily living (ADL)-oriented equipment (five of 36 therapists), 3) sensory re-education equipment (five of 36 therapists), 4) arm supination and pronation training equipment (five of 36 therapists) and 5) wrist extension training equipment (four of 36 therapists).
Discussion Common usage problems of the existing UERE From the usage problem results of the eight types of equipment, most equipment was reported to have two most significant problems: base instability and uninteresting. For the base instability problem, therapists reported that the problem occurred frequently in using these pieces of equipment, and this problem had yet to be resolved. The vertical tower, horizontal tower and single curved shoulder arc (Table I), for example, were unstable and easy to topple when patients exerted excessive force. Unstable pieces of equipment, when they topple, would increase risks for patients as well as damage the equipment. Therapists working in a stroke rehabilitation setting may add weights, anchors or clamps when using the UERE. That is, therapists must adjust the UERE to meet the contextual and safety demands. Because modification of the UERE is part of OT practice, in-service training or workshops focused on modification of the UERE are highly recommended. Our findings may be useful to improve the design of UERE. A possible reason for the base instability problem is that some of the bases of the equipment are made of wood, although light in weight but unable to sustain heavy forces during operation. In addition, the surveyed therapists reported that a narrow base device usually makes its utility more difficult. A possible solution to this problem may be designing the base to be adaptable to fit a vast array of settings where the equipment can be employed. For example, the device may be fixed on the table with a clamping component with a flexible connector adaptable to various devices. Another possibility is to design a standalone base with lockable castors. The base should also have a flexible connector adaptable to various devices. Moreover, it is noted that a narrow base conceptually makes the flexibility of the device useful for multiple situations. For example, smaller equipment is lighter, thus allowing clinicians to take it bedside or 210
into a home setting. Such an advantage should be kept for any new UERE. Furthermore, the advent of interaction technology may offer another potential solution to the weight problem of therapeutic equipment by replacing the physical equipment with virtual interaction equipment. In other words, commonly available digital gaming systems may have a role to play in this situation, creating therapeutic alternatives that are effective and inexpensive, and result in a decrease in hospital expenses over a lifetime (Flynn et al., 2007). Compared with the traditional rehabilitation method, the digital gaming system has several advantages, which include easily set up by individuals, easily adjustable, capable of measurements and able to provide feedback, and the inclusion of stimulus features (Kheng, 2009).
Uninteresting Therapists reported that patients usually felt bored during the treatment process. Patients at each session of therapy take about 15–20 min in repeated use of the equipment, which are common in Taiwan because a therapist usually has to take care of two to three patients at a session. A therapist has to try to motivate patients, for example, by embedding meaningful occupations with the UERE. The outcomes of OT would be best when the tasks employed for patients are meaningful to patients. Many UERE are employed for the purpose of preparing the body for future integrated work. For example, many clinicians begin OT for patients with stroke with a UERE and range of motion therapy prior to engaging the patient and move on to functional reaching tasks. These prior or preparatory activities are part of the treatment process. However, a skilled therapist knows that these tasks are not the end goal of therapy. These tasks are required components and are often only the short-term goals. These short-term goals contribute to longer-term goals like being able to independently do upper-body dressing. A key challenge for a clinician is to motivate a patient through/during the more routine preparatory activities in anticipation of future meaningful occupations. The meaning component in OT is how a therapist utilizes an individual success with the UERE and clearly ties these successes to future purposeful activities. Additionally, a better designed piece of equipment with variable options to choose and fun to use may also be helpful for therapists to plan the therapy activities Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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with interaction and feedback. These therapy activities may raise clients’ motivation to participate in the activities. With the increase of clients’ motivation, both patients’ levels of participation in therapy activities and the therapeutic effectiveness might also increase as a result. Adding new design features for UERE The results on adding new design features to UERE showed that therapists agreed with an integrated design of equipment, which was similar in structure and usage pattern, and they also suggested new function designs for UERE. For integrated design, it would be beneficial to integrate the UERE in current clinical use into a few modular types. There are two possible reasons for integrating the UERE as follows: 1) Many UERE are designed to have the same basic function (e.g. usage pattern and whole structure of the equipment) but are limited to certain functions by size or shape. For example, exercise arm skate and exercise hand skate have the same overall structure and usage pattern, differing only in size. Although this provides a more diverse equipment range, the use of two pieces of equipment raises issues with storage and management. 2) At present, most OT departments face space limitations and budget restraints. Therefore, integration of designs is necessary to save space and costs by integrating equipment with high homogeneity into one product. This suggestion, if applied in equipment development, would reduce equipment development costs in the main mould cost. In addition, in the use of the equipment, such a design could resolve problems of movement and storage of equipment for therapists; patients could remain in a fixed position while using a variety of rehabilitation equipment; and finally, equipment would be easier to manage for therapists or medical equipment managers. New function design Therapists thought that the functions of the existing UERE were insufficient to meet the demands for treatment; therefore, additional UERE were suggested. The therapists’ primary suggestions for designing new equipment were as follows: manual dexterity training equipment, ADL-oriented training equipment, sensory re-education equipment, arm supination and pronation training equipment, and wrist extension training equipment. Because the existing UERE are mainly for motor training of the extension and bending movements Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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of the arm, there is a lack of equipment for other treatment purposes (for example, manual dexterity training equipment, ADL-oriented training equipment, sensory re-education equipment and wrist extension training equipment). Our findings echo those of the previous studies (Bode et al., 2004; Richards et al., 2005) that occupational therapists spent almost half of the therapy time providing interventions that addressed performance skills or body structure, and function impairments, such as motor rehabilitation, cognitive retraining or therapeutic equipment. In addition, Latham et al. (2006) reported that during stroke rehabilitation, about 40% of the OT provided directly targeted life activities (i.e. ADL and instrumental ADL). As upper extremity function improved, ADL training may have progressed from compensatory training to a more remedial approach in which emerging upper extremity motor skills were incorporated into ADL (Richards et al., 2005). Therefore, this points to a need for such equipment in clinical treatment and also provides suggestions on further development of UERE.
Needs in the new design of UERE From the survey results, the three most needed features requiring new equipment design are the following: adjustability in function, interchangeable components and recording of movement data. For adjustability in function, the functions and operational parts of current UERE are fixed and cannot be adjusted to meet the specific needs of different users. In addition, UERE are commonly used with ordinary tables and chairs, not furniture specially designed for use in therapeutic settings. For example, the height and angle of a table surface cannot be adjusted for use with a specific therapeutic UERE or to compensate for the user’s stature, and normal chairs cannot be adjusted to match the patient’s posture or fixed to stabilize the patient’s posture. Because these pieces of furniture are not adjustable, users often experience discomfort while operating the UERE. Therefore, if the functions of a piece of equipment are adjustable according to the patient’s physical condition or needs, it will help patients to implement the therapy activities and help the therapist to custom design different treatment activities. In order to cater to different user operational situations (standing/sitting/wheelchair, etc.) for different rehabilitation UERE, the equipment should be designed with adjustability in function. The basic functions should 211
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include adjustability for the height of the equipment and position of the operation object. These must be designed in a way that facilitates operation of the operation objects and adjustment of the position of the operation objects for therapy activities, and the height of the equipment should be adjustable to be compatible with natural human modes of operation. Interchangeable components We found that interchangeable components are also desirable in design improvement. Many of the current clinical UERE do not have interchangeable operation components and cannot meet the treatment needs of different stroke patients. Therapists noted that when the equipment cannot meet the need for treatment, they must spend much time looking for an alternative commercial, off-the-shelf product to replace the operation components of the equipment. While these alternative products can be used to solve the problem, implementation of the new component may create other problems. For example, the single curved shoulder arc, which uses thin slices of wood and is used to treat problems with distal upper extremity motor impairment, cannot be pinched in a way to operate well. As a result, the therapist needs to wrap the wood with sponges so that these patients will then be able to grip the tube to move the thin slices of wood. However, this is only a temporary solution. Therefore, a better solution would require that the operation components are interchangeable for the users (therapists and patients). Recording of movement data The third major need for design improvement in the UERE was recording of movement data. Lee et al. (2010) found that some therapists tend to use selfdesigned forms for recording treatment data, such as the accomplishment time and the number of operations each time, and use these data as a reference for the expected achievement targets of the patient in the next treatment. Another study conducted by these researchers, on “involving digital games in rehabilitation therapy”, found that some patients would remember personal high scores for each game by himself or herself and expect to break the scores in following sessions (Huang et al., 2012). In view of this point, recording of movement data is indeed needed, for it could provide meaningful and valuable feedback for clinical treatment. Therefore, if this need is implemented, 212
therapists and patients will be provided with useful information to understand their treatment progress and to map out short-term to long-term plans with foreseeable goals for both parties. The further development and investigation of UERE This study reports that usage problems and design improvement needs do exist in UERE. To achieve greater clarity, it also prioritizes the points where design expertise should be focused in the further development of UERE. A similar finding was also reported in Kersten et al. (2000), where equipment needs were identified as one of the seven categories of unmet needs for rehabilitation services. Some studies have also shown that prioritizing problems is a first step to problem solving, a process that has been found helpful in rehabilitation (McGrath and Adams, 1999; Grant et al., 2002; Mackenzie et al., 2007). In view of the continuing technological advances, development and design of new and sufficient UERE for use in rehabilitation are even more essential. In order to improve the quality and effectiveness of OT, we should pursue progress in treatment methods and also advances in therapeutic equipment. To the best our knowledge, the UERE surveyed in this study are generally lacking empirical evidence to support their effectiveness. In addition, as aforementioned, the patients felt bored when using the UERE, and new designs are needed for improving the UERE’s utility. These observations indicate a strong need for examining the effectiveness of the current UERE and the revised UERE, if any in the future. Limitations Though much effort had been exerted to maintain the validity of the questionnaire, there remains one point of concern regarding the results of this survey, hence the limitation of this study. Furthermore, because this survey aimed to verify the usage problems and their improvement needs for UERE, the clinicians’ years of experience were not treated as a variable in this survey. In order to fully understand whether a clinician’s years of experience affects the viewpoint of usage problems and improvement needs, further studies are needed. In addition, the users of the UERE include not only the therapists but also the patients. However, the data in this study were obtained only from Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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experienced occupational therapists. Although expert therapists with much clinical experience and expertise on rehabilitation equipment are able to respond to the questions regarding the current situation and needs, it would be better if the views of patients were also further surveyed. Such an inclusion would be desirable in another research project so as to justify and supplement our findings. A further limitation is that information on whether a clinician selected one piece of equipment over the others was not surveyed. Hence, the clinicians’ preferences on the UERE were not available.
Conclusions This study concludes that therapists indicated that a need did exist for improvements in the current UERE in Taiwan. The major needs for design improvement in the UERE include the following: better stability of the equipment, higher interest in use, adjustability of functions, interchangeability of components and recording of patient movement data. In addition, therapists also suggested that there was need to include new functional design in the UERE: manual dexterity training equipment, ADL-oriented equipment, sensory re-education equipment, arm supination and pronation training equipment, and wrist extension training equipment. These needs and recommendations proposed by experienced occupational therapists should be useful for other clinical practitioners, rehabilitation equipment designers and manufacturers, and other experts in the development of rehabilitation equipment. The use of digital interfaces such as gaming devices for upper extremity therapy would be a much desired direction in equipment design. It is hoped that the information gained from this study can be used to bring the equipment more in line with the goals and true needs of treatment and hence increase the efficiency and safety of upper extremity rehabilitation.
Acknowledgement This study was supported by the National Science Council of the Republic of China with grant no. NSC99-2221-E-040-009. REFERENCES Blaikie N (2003). Analyzing Quantitative Data. London: Sage. Bode RK, Heinemann AW, Semik P, Mallinson T (2004). Patterns of therapy activities across length of stay and impairment levels: Peering inside the “black box” of Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
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inpatient stroke rehabilitation. Archives of Physical Medicine and Rehabilitation 85(12): 1901–1908. Chiang HYA, Pang CH, Li WS, Shih YN, Su CT (2012). An investigation of the satisfaction and perception of fieldwork experiences among occupational therapy students. Hong Kong Journal of Occupational Therapy 22(1): 9–16. Flynn S, Palma P, Bender, A (2007). Feasibility of using the Sony PlayStation 2 gaming platform for an individual poststroke a case report. Journal of Neurologic Physical Therapy 31(4): 180–189. Grant JS, Elliott TR, Weaver M, Bartolucci AA, Giger JN (2002). Telephone intervention with family caregivers of stroke survivors after rehabilitation. Stroke 33: 2060–2065. Huang LL, Lee CF, Chen MH (2012). Usability assessment of off-the-shelf digital game equipments for stroke rehabilitation in Taiwan: usage problems and improvement needs for users. Paper presented at the meeting of the 4th International Conference for Universal Design, Fukuoka, Japan. Jacobs K (2008). Ergonomics for Therapists. (3rd edn). United States: Mosby Elsevier. Kersten P, McLellan DL, Gross-Paju K, Grigoriadis N, Bencivenga R, Beneton C, Charlier M, Keteiaer P, Thompson AJ (2000). A questionnaire assessment of unmet needs for rehabilitation services and resources for people with multiple sclerosis: results of a pilot survey in five European countries. Disability and Rehabilitation 14: 42–49. Kheng TY (2009). Rehabilitation Engineering. India: In-Tech. Latham NK, Jette DU, Coster W, Richards L, Smout RJ, James RA, Gassaway J, Horn SD (2006). Occupational therapy activities and intervention techniques for clients with stroke in six rehabilitation hospitals. The American Journal of Occupational Therapy 60(4): 369–378. Lee CF, Huang LL, Chen MH (2010). An investigation of the upper extremity rehabilitation equipments for stroke patients. Journal of Science and Technology— Humanity and Sociology 19(2): 103–114. Mackenzie A, Perry L, Lockhart E, Cottee M, Cloud G, Mann H (2007). Family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring. Disability and Rehabilitation 30(29): 111–121. Martin JL, Norris BJ, Murphy E, Crowe JA (2008). Medical equipment development: the challenge for ergonomics. Applied Ergonomics 39: 271–283. McGrath JR, Adams L (1999). Patient-centered goal planning a systematic psychological theory? Top Stroke Rehabilitation 6(2): 43–50. Richards LG, Latham NK, Jette DU, Rosenberg L, Smout RJ, DeJong G (2005). Characterizing 213
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Appendices The questions were defined in the questionnaire. Questions Usage problems of UERE Common usage problems
a) Uninteresting b) Easily damaged
c) Height not adjustable d) Base unstable Specific usage problems
e) Additional sandbag f) Inconvenient installation g) Straps easily loosen h) No difficulty level adjustment
Adding new design of UERE
i) Integration of design j) New function design
Improvement needs of UERE
k) Interchangeable components l) Grips adjustable m) Durable material n) Adjustable in function o) Record movement data in each treatment
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Definition Patients usually feel a sense of boredom during the therapy process using these types of equipment. These equipment are easily damaged with unbalanced operation from the patients who, because of lack of control of their body parts, involuntarily exert excessive force or undue action in the operation. The equipment cannot be adjusted to fit patient’s operating height: This would cause inconvenience during the treatment. The equipment is not stable to operate because they do not have a firm base. Equipment with similar functions could be combined and integrated into a single piece of equipment in a new design. Patients cannot easily install equipment with their hands. When using the equipment for an activity, the installed straps easily loosen, causing instability. Operational components of the equipment cannot be adjusted, so some patients are unable to operate it. Equipment with similar functions could be combined and integrated into a single piece of equipment with a new design. It is desirable to add equipment with additional functions in a new design: If you agree, please specify. Interchangeable operable components and operation patterns (such as shapes, materials and weight). Easy to fit hand in different postures. Easy to clean and resistant to abrasion. Adjustable means to provide adaptable features to meet therapeutic needs of the patient’s physical condition. Registration of the patient’s action data would provide the therapist a better understanding of the patient after each treatment, so that he or she can evaluate the effectiveness and efficiency of the treatment.
Occup. Ther. Int. 20 (2013) 205–214 © 2013 John Wiley & Sons, Ltd.
