Occupational therapists’ perspectives on the use of exoskeletons for post-stroke rehabilitation

Robot-assisted upper-limb therapy in research settings has shown improvements in upper limb function, muscle strength, independence in daily activities, and overall patient engagement and motivation (Veerbeek et al., 2017). By providing consistent, measurable, and challenging exercises, robotic therapy enhances feedback and performance data while increasing the efficiency and frequency of therapy (Mehrholz et al., 2018b; Norouzi-Gheidari et al., 2012; Sivan et al., 2011). Clinicians generally have a positive attitude toward robot-assisted therapy; however, real-world implementation poses practical challenges, resulting in robotic tools being left unused.

The purpose of this paper is to comment on robot-assisted stroke rehabilitation from the occupational therapist’s perspective. Feedback is provided by clinicians working with the Harmony Exoskeleton ( Figure 1) for acute post-stroke rehab.

Figure 1. Harmony Exoskeleton can provide bilateral upper-body training in stroke survivors.

Key features

Range of motion to allow for functional movements

Integrating functional movements into robot-assisted therapy is beneficial and motivational for patients (Mehrholz et al., 2018a; Veerbeek et al., 2017). Compared to previous upper extremity stroke rehabilitation robots, Harmony provides an extensive range of motion allowing clinicians to devise creative interventions and treatments. However, the Harmony Exoskeleton can still expand its capabilities to include dynamic movement at the wrist and grasping of the hands. The Harmony exoskeleton also requires the patient to be seated, limiting the robot’s use to seated activities.

Limb support

The use of robot-assisted technology is complementary to other forms of therapy and the use of graded limb support allows greater repetitions of treatments compared to manually supporting the patient’s limb (Hamilton et al., 2019; Mashizume et al., 2021; Stephenson & Stephens, 2018). Due to the increased efficiency, the use of robot-assisted therapy can further promote neuromuscular re-education and foster neuroplasticity without concerns about the physical onus on therapists (Turner et al., 2013).

In contrast, we observed that Harmony could be limiting for patients who have progressed and no longer derive benefits from the support—phasing out the technology sooner than they might like. For example, one patient had reached the lowest support level offered by Harmony, however, without support, he still struggled to use his upper limb functionally. This suggests the need for further gradations to bridge the gap between the minimum support level and the complete lack of support.

Measurable feedback

Robot-assisted therapy allows for clear and measurable feedback on the patient’s progress, such as assistance levels used by the patient. This data could enhance clinician and patient understanding of changes on a session-to-session basis informing clinical decisions and improving patient communication of progress. The Harmony exoskeleton can also provide an objective assessment of motor activities and a comparison of the affected and unaffected sides enabling therapists to customize training according to individual needs.

While we had positive responses to Harmony’s ability to provide quantitative data, we are interested in more advanced data about the quality of movements, range of motion, and mapping of the applied forces from the user. Ultimately, robot-assisted therapy is a promising way to document progress with tangible data, while saving time and informing interventions making them more efficient and effective.

Identifying suitable clients

Identifying suitable clients and windows of opportunity has been emphasized as a crucial factor in effectively implementing and regularly utilizing robot-assisted technology (Flynn et al., 2019). The study team discussed the ideal conditions and user characteristics for the use of the Harmony exoskeleton including intact cognition, communication skills, activity tolerance, intact visual field, the ability to attend to the affected side, and some return in abilities, but not so much return that the robot becomes a constraint ( Figure 2).

Figure 2. Clinicians discussed ideal user of the Harmony Exoskeleton.

Technical difficulties and usability

Like any technology, the Harmony exoskeleton occasionally experienced technical difficulties or malfunctions, which interrupted therapy sessions and caused frustration. We found the management of the robot challenging. This speaks to the need to increase comfort with the device, smoothing out the process overall, and developing a clinical-based interface. This finding aligns with the results of other studies that have examined clinician perspectives on the use of robot-assisted technology (Chen & Bode, 2011; Flynn et al., 2019).

Conclusion

While the thoughts in this report center on the experience of using the Harmony Exoskeleton, these commentaries provide valuable insight to better inform robot design bridging the gap from research to implementation. Continued research and development of the Harmony exoskeleton and similar technology, incorporating the lessons learned from end-users, is necessary to maximize the potential of the technology’s impact on clinical care for stroke rehabilitation.

Ethics and consent

Ethical approval and consent were not required.