F1000Research F1000Research 2046-1402 F1000 Research Limited London, UK 10.12688/f1000research.161900.1 Opinion Article Articles Occupational therapists’ perspectives on the use of exoskeletons for post-stroke rehabilitation

[version 1; peer review: 1 approved with reservations]

 Muir Brittney Conceptualization Data Curation Funding Acquisition Project Administration Supervision Writing – Original Draft Preparation Writing – Review & Editing https://orcid.org/0000-0002-0978-5524 a 1 2 Teng Tiffani Data Curation Writing – Original Draft Preparation 1 3 Nagle-Chrsitensen Avocet Writing – Original Draft Preparation 1 Lacey Abbey Data Curation Writing – Review & Editing 3 Geller Claira Data Curation Writing – Review & Editing 3 Stutzenberger Matthew Data Curation Writing – Review & Editing 3 Howard Ileana Conceptualization Data Curation Funding Acquisition Writing – Review & Editing 3 4 Department of Veterans Affairs, RR&D Center for Limb Loss and MoBility (CLiMB), Seattle, WA, 98144, USA Department of Mechanical Engineering, University of Washington, Seattle, WA, 98144, USA Department of Veterans Affairs, Rehabilitation Care Services, Seattle, WA, 98144, USA Department of Rehabilitation Medicine, University of Washington, Seattle, Washington, 98144, USA bcmuir@uw.edu

No competing interests were disclosed.

 21 2 2025 2025 14 225 13 2 2025 Copyright: © 2025 Muir B et al. 2025 This is an open access article distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Robot-assisted therapy is a promising approach to enhance stroke rehabilitation, particularly in improving upper-limb function through intensive and repetitive training. Successful integration of technology into clinical practice relies on therapists’ acceptance and endorsement. Our purpose is to share the perspectives of the occupational therapists who facilitate robot-assisted therapy and the benefits and challenges of practical implementation of the robot. Clinicians who worked with stroke survivors to research the usability, feasibility, and efficacy of the Harmony exoskeleton discuss their impressions of the technology on stroke rehabilitation. Overall, therapists expressed positive views on the therapeutic and adjunctive use of robot-assisted technology, emphasizing patient engagement, objective evaluations of progress, and ease of certain aspects of their role. Additional feedback highlighted the Harmony exoskeleton’s ability to promote neuromuscular re-education and foster neuroplasticity. Barriers to implementation include physical capabilities, patient suitability, technical difficulties, and the need for advanced quantitative feedback and data analysis. To maximize the impact of robot-assisted therapy in stroke rehabilitation, ongoing research and development are necessary to address identified challenges. Improved limb support, quantitative feedback, equipment reliability, and more levels of weight support for patients with higher levels of function may improve therapist acceptance of this device and may inform exoskeleton development.

 Stroke Rehabilitation Exoskeleton Robotics Occupational Therapy Department of Veterans Affairs PugetSoundHealthCareSystemSeedAward This work was supported by a Department of Veterans Affairs, Puget Sound Health Care System Seed Award. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. <p>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 ( <xref ref-type="bibr" rid="ref11">Veerbeek et al., 2017</xref>). By providing consistent, measurable, and challenging exercises, robotic therapy enhances feedback and performance data while increasing the efficiency and frequency of therapy ( <xref ref-type="bibr" rid="ref6">Mehrholz et al., 2018b</xref>; <xref ref-type="bibr" rid="ref7">Norouzi-Gheidari et al., 2012</xref>; <xref ref-type="bibr" rid="ref8">Sivan et al., 2011</xref>). Clinicians generally have a positive attitude toward robot-assisted therapy; however, real-world implementation poses practical challenges, resulting in robotic tools being left unused.</p> <p>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 ( <xref ref-type="fig" rid="f1"> Figure 1</xref>) for acute post-stroke rehab. </p> <fig fig-type="figure" id="f1" orientation="portrait" position="float"> <label> Figure 1. </label> <caption> <title>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).

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.

 Data availability statement

No data are associated with this article.

 References Chen CC Bode RK : Factors influencing therapists’ decision-making in the acceptance of new technology devices in stroke rehabilitation. Am. J. Phys. Med. Rehabil. 2011;90(5):415–425. 21765257 10.1097/PHM.0b013e318214f5d8 Flynn N Kuys S Froude E : Introducing robotic upper limb training into routine clinical practice for stroke survivors: Perceptions of occupational therapists and physiotherapists. Aust. Occup. Ther. J. 2019;66(4):530–538. 31292975 10.1111/1440-1630.12594 Hamilton C Lovarini M McCluskey A : Experiences of therapists using feedback-based technology to improve physical function in rehabilitation settings: a qualitative systematic review. Disabil. Rehabil. Taylor and Francis Ltd.;2019;41(15):1739–1750. 29513052 10.1080/09638288.2018.1446187 Mashizume Y Zenba Y Takahashi K : Occupational therapists’ perceptions of robotics use for patients with chronic stroke. Am. J. Occup. Ther. 2021;75(6). 34787638 10.5014/ajot.2021.046110 Mehrholz J Pohl M Platz T : Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst. Rev. John Wiley and Sons Ltd.;2018a;2018(9):CD006876. 30175845 10.1002/14651858.CD006876.pub5 PMC6513114 Mehrholz J Pohl M Platz T : Electromechanical and robot-assisted arm training for improving activities of daily living, arm function, and arm muscle strength after stroke. Cochrane Database Syst. Rev. 2018b;2018. 10.1002/14651858.CD006876.pub5/full Norouzi-Gheidari N Archambault PS Fung J : Effects of robot-assisted therapy on stroke rehabilitation in upper limbs: systematic review and meta-analysis of the literature. J. Rehabil. Res. Dev. 2012;49(4):479–496. 22773253 10.1682/JRRD.2010.10.0210 Sivan M O’Connor RJ Makower S : Systematic review of outcome measures used in the evaluation of robot-assisted upper limb exercise in stroke. J. Rehabil. Med. 2011;43(3):181–189. 21305232 10.2340/16501977-0674 Stephenson A Stephens J : An exploration of physiotherapists’ experiences of robotic therapy in upper limb rehabilitation within a stroke rehabilitation centre. Disabil. Rehabil. Assist. Technol. 2018;13(3):245–252. 28366037 10.1080/17483107.2017.1306593 Turner DL Ramos-Murguialday A Birbaumer N : Neurophysiology of Robot-Mediated Training and Therapy: A Perspective for Future Use in Clinical Populations. Front. Neurol. 2013;4. 24312073 10.3389/FNEUR.2013.00184 PMC3826107 Veerbeek JM Langbroek-Amersfoort AC Van Wegen EEH : Effects of Robot-Assisted Therapy for the Upper Limb After Stroke. Neurorehabil. Neural Repair. 2017;31(2):107–121. 10.1177/1545968316666957 10.5256/f1000research.177993.r369348 Reviewer response for version 1 Takhakh Ayad M. 1 Referee https://orcid.org/0000-0002-7242-0405 Sarhan Saad M. 2 Co-referee https://orcid.org/0009-0006-8174-7342 Al-Nahrain University, Baghdad, Iraq Biomedical Engineering department, College of Engineering, Al-Nahrain University, Baghdad, Iraq

Competing interests: No competing interests were disclosed.

 11 3 2025 Copyright: © 2025 Takhakh AM and Sarhan SM 2025 This is an open access peer review report distributed under the terms of the Creative Commons Attribution Licence, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. recommendation approve-with-reservations

Comments :

Title:

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

The title is clear and accurately reflects the content of the manuscript.

Abstract:

The abstract provides a concise overview of the study's purpose, methods, and key findings. It highlights the positive views of occupational therapists on robot-assisted therapy, particularly the Harmony exoskeleton, while also noting challenges such as technical difficulties and the need for further development. The abstract is well-structured and informative.

 Introduction:

The introduction sets the stage by discussing the potential of robot-assisted therapy in stroke rehabilitation and the importance of therapist acceptance. It clearly states the purpose of the paper, which is to share occupational therapists' perspectives on the Harmony exoskeleton. The introduction is well-written and provides sufficient background information.

 Key Features:

This section effectively outlines the key features of the Harmony exoskeleton, including its range of motion, limb support, and measurable feedback. The discussion on the limitations, such as the need for dynamic wrist movement and more gradations in limb support, is insightful and highlights areas for improvement.

 Identifying Suitable Clients:

The criteria for identifying suitable clients for the Harmony exoskeleton are clearly presented. The emphasis on intact cognition, communication skills, and activity tolerance is relevant and practical. This section provides valuable guidance for clinicians considering the use of this technology.

 Technical Difficulties and Usability:

The discussion on technical difficulties and usability challenges is important and aligns with findings from other studies.

 Conclusion:

The conclusion succinctly summarizes the key points and emphasizes the need for continued research and development to maximize the potential of robot-assisted therapy in stroke rehabilitation.

 References:

The references are relevant and support the content of the manuscript. They are appropriately cited and provide a good foundation for the discussion.

 Overall:

The manuscript is well-written and provides valuable insights into the use of the Harmony exoskeleton from the perspective of occupational therapists. The structure is clear, and the content is informative. The manuscript would benefit from addressing potential biases and limitations more explicitly, but overall, it is a strong contribution to the field of stroke rehabilitation.

 Suggestions for Improvement:

Expand on Limitations: Consider adding a section that explicitly discusses the limitations of the study, such as potential biases or the generalizability of the findings.

Future Research: Include a brief discussion on future research directions to address the identified challenges and further validate the findings.

User Interface Development: Emphasize the importance of developing a more intuitive and clinician-friendly interface for the Harmony exoskeleton to improve usability and adoption.

Is the topic of the opinion article discussed accurately in the context of the current literature?

Partly

Are arguments sufficiently supported by evidence from the published literature?

Yes

Are all factual statements correct and adequately supported by citations?

Yes

Are the conclusions drawn balanced and justified on the basis of the presented arguments?

Yes

Reviewer Expertise:

Prosthetics and Orthotics

We confirm that we have read this submission and believe that we have an appropriate level of expertise to confirm that it is of an acceptable scientific standard, however we have significant reservations, as outlined above.