Reaching in Stroke 3rd Phase
Reaching in Stroke 3rd Phase
The project targets stroke survivors to investigate the effect of augmented feedback (using
 robotic force cues and visual feedback) and rewards (game scores), on their upper limb
 reaching patterns and trunk compensatory movements
Purpose:

 For stroke survivors, the use of compensatory movements can lead to a reduction of range of
 motion, pain, and a pattern of "learned non-use". A common compensatory movement present
 during upper limb reaching is trunk displacement. Although this motion has been identified as
 an important one to be reduced, few strategies for addressing this problem have been
 considered. The existing strategies require physical restraint of the person to the back of a
 chair, making them undesirable for use in unsupervised therapy. As a result, there is a
 current need for alternate methods that promote the use of correct movement patterns both in
 the clinic and in the home. In this sense, technology can act as an enabler to create new
 ways of reducing trunk compensation. Still, there is a gap in the literature as trunk
 compensation has only been investigated as a secondary theme in robotic and computer-aided
 rehabilitation.

 Consequently, in this project the investigators will look into the reduction of trunk
 compensation using robotic devices and commercially available technology, to enable a focus
 on the quality of the movements in unsupervised therapy. The potential results from this
 project could later be applied and generalized to other modes of compensation in stroke and
 other neurological disabled populations.

 Objective:

 The objective is to demonstrate that feedback cues and rewards (game scores) could be used to
 reduce trunk compensatory movements in unsupervised therapy.

 Research Questions:

 Will the use of visual+force feedback and the use of visual+force+game scores feedback reduce
 trunk compensation?

 Will one of these feedback modalities (visual+force vs. visual+force+game scores) be more
 effective in reducing trunk compensation?

 Equipment:

 -  1 Kinect (Microsoft, Inc.) markerless motion capture system.

 -  2 Kinova Jaco assistive robotic arms. These devices are used to assist disabled people
 on daily tasks. The arms are designed for safe interaction (low forces) with the user.

 -  1 Desktop computer and a monitor to deliver the visual feedback.

 Method:

 The investigators will implement the force feedback cues using two Kinova Jaco robotic
 devices to deliver them. The force feedback cues will be provided as resistance to move the
 robots' handles. These cues will be applied when the user moves outside a certain error band,
 based on a "normal" reaching pattern. In addition, the magnitude of the cue will be
 proportional to the magnitude of trunk compensation. The visual cues will be implemented
 using a monitor to display two cursors (empty circles) that will represent the participant's
 hands, and the circles will fill with red ink as the user starts to compensate. As the
 magnitude of compensation increases, the amount of red ink will gradually increase to
 indicate the level at which the user is compensating. For the game scores, the participant
 will be rewarded with more points when less compensation is exhibited, or with less points
 when an increased level of compensation is measured. .

 In the study, the investigators will compare the combination of visual+force feedback vs.
 visual+force+game scores feedback.

 The goal of this approach is to investigate whether using compensatory motions to affect the
 outcome of the game scores would lead to a further reduction of these movements when compared
 to only receiving feedback about the movement pattern without attaching a reward to it. This
 approach will follow an operant conditioning strategy to attempt to change the subject's
 behaviour when performing unrestrained bimanual exercises.

 Summary of Procedures:

 (Total Time: 2-2.5 hours):

 1. Participants will be recruited.

 2. Introduce the study and equipment. Participants will be asked to inform the investigator
 if they feel uncomfortable or fatigued at any point during the experiment, and will be
 given as many breaks as needed.

 3. Ask participants to fill out consent forms, or if their unable to provide consent due to
 their health condition, their caregivers/guardians will provide consent and the subject
 will provide assent.

 4. Participant will fill out a background questionnaire and a registered physical therapist
 will conduct a clinical assessment based on recognized impairment scales (Fugl-Meyer
 Upper Extremity Assessment and Reaching Performance Scale) to use the scores as a
 baseline for the comparisons that will be performed in the statistical analyses at the
 end of this phase. The Reaching performance Scale requires the use of video recording of
 the assessment for scoring. If the participant wants to know their clinical assessment
 results, at the end of the session, the therapist will provide a photocopy of the
 results, and will give the participant and explanation of these results and answer any
 questions that the participant may have about these scales. In the case of the Reaching
 Performance Scale as the scoring is done after the study, the participant could receive
 their scores at a later date via a telephone call.

 5. All the study sessions will be conducted at the University of British Columbia (UBC)
 Point Grey Campus. During the test, the participants will be asked to interact with a
 computer through the use of the following input technologies: 2 Jaco Kinova robotic arms
 and a Microsoft Kinect. Using these technologies, the participants will perform bimanual
 symmetric movements with their arms/ hands to control a simple cursor/target videogame.
 The Kinect will measure the participant's movement as data points for every joint, no
 video will be recorded.

 The robotic devices will be used to record the hands' movements and will increase their
 resistance to be moved based on the level of trunk compensation of the participant. The
 monitor will be used to provide visual feedback about the participant's trunk
 compensation and to display the target game and game scores.

 6. Ask participants to sit in a chair and adjust footrest to have their feet fully
 supported, their knees at a 90 degree angle, and their back against the chair.

 7. Ask participants to hold on to the handles of the two robotic devices.

 8. In case participants are not able to hold the handle due to hand weakness, an adjustable
 fabric and elastic strap will be fitted around their palm to hold the hand on top of the
 handle.

 9. The maximum force that the user can produce to push the robots will be measured by
 reading the robot's sensors.

 10. Ask the participant to perform a series of unimanual reaches to calibrate the system
 based on the participant's arm's length.

 11. Ask participant to perform 5 practice bimanual reaches to become familiar with the
 system and the motion mapping.

 12. Ask participant to perform 15 baseline (no feedback) bimanual reaches to measure their
 trunk compensation. The investigators will use the value of average trunk compensation
 to set the error bands for the visual and force feedback.

 13. Ask participant to perform 5 practice bimanual reaches to become familiar with either
 the visual+force feedback, or the visual+force+game scores (depending on the
 randomization of subjects).

 14. Ask the participant to perform 60 trials of bimanual reaches to 1 target at knee height
 with arms fully extended. Participants will receive visual feedback about their
 compensation and their accumulated game scores through the computer's monitor, and as
 increased resistance to move of the robots.

 15. The participant will be able to rest between targets if requested. In addition there
 will be 1 minute rests after every 15 targets.

 16. The participant will perform 15 reaches without any feedback (Post measurement)

 17. The participants will have 5 minutes of break before starting the second feedback
 condition.

 18. Repeat steps 14, 15 and 16, but with the other type of feedback (visual+force, or
 visual+force+game scores).

 19. A note taker will record the occurrence of obstacles encountered by the participants
 during the study.

 20. The motion tracking data and assessment videos will be saved on a computer file, backed
 up on a UBC-based file server and on optical media.

 21. At the end of the session the participant will answer a usability questionnaire.

 22. The data from the note taker, motion logs, assessment videos and questionnaires will be
 used to conduct a quantitative and qualitative analysis to gain further insight into how
 augmented feedback can reduce compensatory trunk movements, and the ease of use and
 functionality of the system. All the data will be identified using participants'
 numbers.

 23. The video recordings will be erased/destroyed 5 years after publication of results.

 Study Design:

 The investigators will follow a within-subjects crossover design with the independent
 variable being the feedback type and the levels will be: visual+force feedback and
 visual+force+game scores. The primary dependent variable will be the measure of trunk
 compensation.

 The investigators will follow a counterbalanced strategy to reduce the carryover effects from
 performing the two conditions in a certain order. Data collection will include motion log
 files, scores from the game, discussions with participants and exit surveys.
Inclusion Criteria:

 -  At least 19 years old

 -  Hemiplegia as a result of a non-traumatic cerebral stroke (ischaemic or hemorrhagic)

 -  Stroke occurred at least 3 months prior to study

 -  Ability to understand/follow directions and answer questions in English

 -  Ability to maintain a sitting position in a standard office chair without arm rests,
 independently or with minimal supervision, for 1.5 hours.

 -  Have the ability to perform the following movement several times with their weak arm
 (while seated): move their hand to their hip (on the same side as the weak arm), it's
 OK if they use their trunk to help themselves, and from that point of flexion moving
 it forward (without touching their thigh) to touch their knee (on the same side as the
 weak arm). They should be able to do this movement without any help from their strong
 hand.

 Exclusion Criteria:

 -  Upper limb orthopaedic surgery in the past 3 months

 -  Shoulder subluxation or significant shoulder pain

 -  Trunk pain

 -  Other orthopaedic or neurological conditions affecting the arm or trunk

 -  Severe uncorrected visual impairment that could prevent participants from completing
 the task