Inclusive design in electrical stimulation technologies and neurorehabilitation for clinician and patient end users

Abstract

Dr. Tamsyn Street is an interdisciplinary researcher working for the National Health Service (NHS) in the UK with a background in motor neurorehabilitation. In the last couple of decades there has been a rapid advancement in assistive technology solutions using electrical stimulation for neurorehabilitation. This editorial examines whether these advancements have translated into good inclusive design performance for clinician and patient end users. Suggestions for overcoming some of the existing challenges are proposed.

In the last couple of decades there has been a rapid advancement in assistive technology solutions using electrical stimulation for neurorehabilitation. Electrical stimulation technologies have been proposed to support a wide range of neurorehabilitation applications, the most common applications include functional electrical stimulation (FES) assisted walking, strength training and upper limb control. Whereas, in the past there would be one or two commercially available devices for any application, there is now an ever-increasing variety of devices, introducing greater choice to the clinician and patient end user to find the right option to suit personal needs and preferences.

Despite the increase in the variety of devices available this has not always translated into good inclusive design performance for clinician end users. USA physiotherapists were found to be less confident with decision making for functional electrical stimulation (FES) than with ankle foot orthoses for their patients and reported needing more education with FES. ¹ In one study, only 16% of Scottish therapists, reported high confidence levels in selecting appropriate parameters for FES upper limb treatment poststroke. ² A recent study with UK and USA FES physiotherapists was consistent with previous work. Limited ongoing support following initial educational courses was reported as a factor influencing confidence in using FES. Clinicians also expressed difficulty, with keeping up to date with the increasing number of available FES devices, due to limitations of funding, time and resources. ³ Recently published comprehensive clinical practice guidelines (CPG) for FES walking, provide best practice recommendations and a framework for education, to guide development of courses and resources.^4,5 The development of CPG for other FES applications is now required. While CPG may mitigate some of the identified issues, there is also a need for evidence based academic resources such as course textbooks, to support the development of higher education level courses. Concomitantly, harnessing and commercializing technological developments, which reduce burden and improve confidence in the use of the technology, such as device estimation of optimum parameters, may be helpful for improving accessibility.

If FES can be a challenge for clinician end users, what about the FES patient end user? There is a lack of comprehensive published research in this area, possibly due to commercial sensitivity. Research that has been published in the area, often tends to focus on the perspective of the clinician or the patient in isolation. Future work will benefit from being inclusive of the perspective of the patient, the clinician and the engineer as well as including the dialogue between them, to provide a more transparent picture of the limitations and goals of each stakeholder in the design process.

While the regulatory framework for medical device development and grant bodies will require the involvement of the end user at different stages of the design process, there is a risk of this becoming a tick box exercise and missing the opportunity for constructive input to the design process. Empowering each stakeholder with information that will enable FES technology development teams, to nurture an honest open environment, can lead to more constructive communication and device development.