Abstract
Findings from this research provide insights into using robotics to enhance occupational therapy practice.
As technology advances worldwide, the use of assistive technologies by occupational therapy practitioners becomes increasingly important, and the use of robotic therapy in stroke rehabilitation is a recent practice using technology in occupational therapy. Robotic therapy is recommended by the Guidelines for Adult Stroke Rehabilitation and Recovery (Winstein et al., 2016), and its efficacy has been confirmed by multiple studies reporting improved upper extremity (UE) function (Takahashi et al., 2016) and cost benefits (Lo et al., 2019), especially for clients in the chronic phase after stroke (Bertani et al., 2017). Similarly, a recent systematic review suggested that robotic therapy is effective for activities of daily living (ADLs; standardized mean difference [SMD] = 0.37, 95% confidence interval [CI] [0.11, 0.64], p = .005), in addition to body function (SMD = 0.35, 95% CI [0.18, 0.51], p < .0001; Mehrholz et al., 2018), although no significant differences in the amount of use or quality of movement (p = .982 and p = .943, respectively) of the affected hand were observed in a clinical trial (Takahashi et al., 2016). A pilot study has indicated that therapist-guided behavioral techniques, combined with robotics, affected post hoc tests of clients’ use of the affected hand in daily living (Cohen’s d = 1.21; Fasoli & Adans-Dester, 2019). Thus, occupational therapists’ use of this technology is recognized worldwide, and its importance will likely increase in the future.
Despite the efficacy and clinical usability of robotics, the number of occupational therapists incorporating this therapy into their daily practice is limited. Chen and Bode (2011) stated that the introduction of new equipment, such as robotics, is influenced not only by therapists’ recognition of its advantages but also by clients’ needs and the workplace’s understanding of the technology. Previous research has found that physical therapists have positive attitudes regarding the use of robotics as a person-centered adjunct to other therapy (Stephenson & Stephens, 2018). On the basis of a survey of therapists, Lu et al. (2011) noted that therapists’ opinions were predictive of future use of upper-limb rehabilitation robots. Accordingly, there appears to be a need to analyze occupational therapy practitioners’ perspectives regarding the advantages of robotics in occupational therapy. However, no previously published study has mentioned occupational therapists’ perceptions of robotics and how they use this technology as an adjunct to other therapy. Because use of technology is a research priority in the field of occupational therapy (Mackenzie et al., 2017), exploring occupational therapists’ perspectives provides an important contribution to this field.
Thus, the aim of this study was to explore occupational therapists’ perceptions of the mechanisms and outcomes of robotics use in occupational therapy for patients with chronic stroke. This research demonstrates the ingenuity of occupational therapy profession when using robotic technology.
Method
This study had a qualitative descriptive research design. As noted by Diers (1979), this design is appropriate when a phenomenon cannot be clearly categorized into quantitative variables. We obtained ethics approval from the institutional review board of the School of Allied Health Sciences, Kitasato University (Reference No. 2018–020) and followed the Journal Article Reporting Standards for Qualitative Research recommendations (Levitt et al., 2018) in the preparation of this article. All participants provided written informed consent.
Participants and Settings
The participants were occupational therapists who had clinical experience using the ReoGo®-J robotics device (Teijin Pharma Ltd., Tokyo, Japan; Figure 1) to guide self-training that involves repetitive movements of the paralyzed UE. The participants had experience using this device with more than one patient with chronic stroke (≥6 mo after acute stroke). The participants were employed at hospitals and clinics that provided outpatient rehabilitation services for these patients. For theoretical variations in expertise, we recruited participants with various years of experience and clinical experience in treating conditions other than stroke. In the Takebayashi et al. (2018) study that aimed to verify the efficacy of therapy using robotics, a snowball sampling method was initially used to recruit study participants.
ReoGo®-J robotic therapy device.
In this study, the occupational therapists conducted traditional training (stretching, joint range-of-motion exercises, coordination training, and ADL training) for 1 hr, 3 times a week, for 10 wk, and with the partial use of robotics for patient self-training. Focus groups were created in each institution in which the study participants worked. After confirming that they met the study criteria, the first author (Yuki Mashizume) obtained written informed consent from all participants. The sample size was based on previous research finding that code saturation is reached at nine interviews (Hennink et al., 2017).
Data Collection
Data were collected via face-to-face semistructured focus group interviews by the first author. These interviews are appropriate for exploring the inclusive perceptions of occupational therapists with various clinical experiences. An interview guide, shown in Figure 2, was developed for this study. All interviews were conducted by the first author, who was a graduate student licensed as an occupational therapist in Japan and who had experience in qualitative research but no clinical experience using robotics. The focus group interviews were audio recorded and transcribed verbatim. Data collection was performed from November 2018 to February 2019.
Interview guide.
Analysis
Data were analyzed using thematic analysis (Braun & Clarke, 2006). The first author, who was responsible for the entire analysis process, coded the data and then aggregated them into themes and subthemes. After the initial codes were grouped into subthemes, the subthemes were discussed and revised by the other two authors (Yosuke Zenba and Kayoko Takahashi). Preliminary main themes were evaluated to ensure congruence with the raw data and to address the research issue. To incorporate occupational therapists’ perspectives, we applied the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; OTPF–3; American Occupational Therapy Association [AOTA], 2014) as a reference to understand the role of robotics in occupational therapy. We deductively developed the themes on the basis of domains in the OTPF–3 and integrated codes from qualitative data. In the inductive analysis process, we developed codes and subthemes for mechanisms in occupational therapy practice using robotics. Data analysis was completed using MAXQDA qualitative software (VERBI, Berlin, Germany).
Trustworthiness
Qualitative research embraces creditability, transferability, dependability, and confirmability as the standards of trustworthiness (Guba, 1981). We used the strategies of triangulation and reflexive discussion. Triangulation was performed for data gathered from occupational therapists with multiple clinical experiences and varied duration of experience. Peer checking in reflexive discussion with researchers who had no experience using robotics in stroke rehabilitation was used to help limit the biased influence of single perspectives (Morrow, 2005) while developing codes and themes. For transferability, we adopted the OTPF–3 as an analysis framework to understand occupational therapists’ general perceptions.
Results
As shown in Table 1, this study included 27 occupational therapists in nine focus groups. Each group consisted of occupational therapists working at the same institution. The participants had an average of 7.9 yr (range = 2–17 yr) of clinical experience and worked primarily in adult physical rehabilitation settings. The average duration of each interview was 57.2 min (range = 41.1–65.3 min). Potential participants’ reasons for not enrolling in the study were schedule conflicts or lack of interest. Five themes based on the OTPF–3 and 12 subthemes were identified from the qualitative data (Table 2).
Participant Demographics
Themes, Subthemes, and Example Quotes
Note. OT = occupational therapist/occupational therapy; UE = upper extremity.
Body Function
This theme represented body function with respect to physiological function. Participants in all focus groups described the main outcome of robotics as improved UE function. Occupational therapists regarded robotics as a means to improve body function to accomplish the ultimate goal of increasing use of the affected arm in ADLs. Some participants felt that robotics would provide patients with more structured training—with a fixed range of motion and number of movements—compared with hands-on movement therapy. Because outcomes related to improvement of UE function, participants identified changes in muscle tone and pain, and some occupational therapists felt that these changes led to changes in trunk function. As 1 participant described, these outcomes were associated with the salient features of robotics: I felt that the advantage of using robotics was repetitive training with just the right resistance and structured training with safety. It has impacted patients’ UE function and trunk function, improving their walking. Thus, robotics has many advantages as a whole. (Participant 9)
Values
The values theme included patients’ perceptions, motivations, and related concepts that influence or are influenced by engagement in occupations. Improved body function gained by robotics motivated patients to attempt activities they had discontinued after their stroke. In addition, occupational therapists felt that robotics provided a sense of agency, even for patients with severe paralysis, because hand movements assisted by robots were produced without direct handling by an occupational therapist. Moreover, occupational therapists felt that the improved sense of agency was accompanied by greater adherence to exercise. A participant stated, Training provided by robotics is completely up to the patients themselves. Performing active movements by themselves makes them more independent not only physically but also psychologically, as was apparent in their behaviors and words. I think trainings with robotics structured by number of times or duration of trainings give patients [a] sense of accomplishments. (Participant 5)
The positive attitudes toward training interrelated with their desire for independence in activity performance.
Performance Skills
Performance skills referred to observable elements of action with an implicit functional purpose. Participants reported that the prominent process while using robotics was gaining skills by trial and error. This occurred because robotics enabled patients to perform exercises with a sense of agency within the range and movements fixed by robotics, which are regarded as the main advantages of this technology. By gaining skills through trial and error, patients improved stabilization and reaching movements, as indicated by a participant who said, I was in charge of a patient who had difficulty with external rotation of the shoulder. The patient gradually realized how the UE moved during repetitive movements with trial and error provided with robotics. After using robotics, I noticed that reaching movement, which involved external rotation of the shoulder, was improved when we tackled movements in [ADLs]. (Participant 10)
Occupational Performance
This theme was defined as the act of doing and accomplishing a selected action, activity, or occupation. Other outcomes associated with occupational therapy using robotics, such as improvements in body function and desire for independence, led to improved occupational performance in daily living. Occupational therapists influenced patients’ performance by adapting their improved body function to their desired occupations. As noted by a participant, occupational therapists suggested that patients use their affected arm in ADLs and provided task-oriented training after they gained a sense of agency: “I got a patient to do training with robotics, which enables patients to recognize the potential capacities of [the] affected arm, and I provided a task-oriented activity. In the end, this resulted in gain of use of the affected arm” (Participant 1). Consequently, patients changed their behavior by themselves as they became self-aware of the body function gained via robotics: “Patients told me that they tried to use their affected arm in their daily activities autonomously. It occurred when their body function got improved with robotics” (Participant 8).
Participation
The participation theme reflected patients’ engagement in their desired occupations in ways that were personally satisfying and congruent with cultural expectations. Participants indicated that improved UE function gained via robotics led to increased use of the affected arm and thus improved engagement in their occupations. Moreover, changes in patients’ desire and motivation acted synergistically to promote participation in their desired occupations. Ultimately, changes in the patients’ condition resulted in behavioral changes: The patient applied behavioral techniques after robotic therapy to enhance the synergistic effect between function and behavior, and as a result, [OTs] could have brought synergistic effects both on shoulder movement as function and use of the affected hand in the desired occupation as behavior. . . . Eventually, the patient voluntarily tried other desired occupations without [them] being suggested by OTs. (Participant 24)
Discussion
Robotic therapy has the notable strengths of providing automated practice of repetitive movement patterns, programmable levels of assistive and resistive training to meet individual patient needs, and objective evaluation of motor activities (Fasoli et al., 2004). In the current study, we collected qualitative data regarding occupational therapists’ experiences to gain valuable information regarding the mechanisms and outcomes of occupational therapy using robotics. Our findings showed that occupational therapists made good use of robotics to improve patients’ body function and promote their desire for independence, and study participants indicated that they regarded robotics as a useful way to enhance these goals. Occupational therapy practitioners focus on optimizing the ability to participate in desired occupations as a way to promote health, well-being, and participation in life (AOTA, 2014), and occupational therapists perceive technology as an adjunct to other therapy (Hamilton et al., 2019). Thus, occupational therapists should evaluate their own professional perspectives and take advantage of the benefits provided by robotics.
When using robotics training, occupational therapists play an important role in adjusting the degree of difficulty to each patient’s body function and goals. The robotic device used by participants in this study can be adjusted by selecting parameters such as movement patterns and phased robotic assistance, which enables therapists to select the appropriate training for each person. As noted in previous research (Barker & Brauer, 2005), therapists should match their services to the aspirations of individual stroke survivors while helping them work toward recovery. It has been recommended that technology be tailored to patients and their goals (Hochstenbach-Waelen & Seelen, 2012). Therefore, occupational therapists should determine patients’ ability to engage in their occupations and then provide them with adequate training to complete the required tasks in accordance with their sense of agency. In the clinical setting, most occupational therapists use active-assistive levels (Basteris et al., 2014) to facilitate a sense of agency. Thus, occupational therapists should consider robotics as a useful tool in clinical settings, evaluating patients’ performance and ensuring the appropriate quality and quantity of movements for recovery (Hamilton et al., 2019).
Occupational therapy using robotics is a novel mechanism based on current concepts of rehabilitation. In our study, occupational therapists reported that robotics improved patients’ body function and promoted desire for independence, which resulted in improved occupational performance and participation in desired occupations. In addition, a change in psychological condition occurred as a result of the sense of agency gained during robotics training. It is thought that trial-and-error processes during training facilitate patients’ learning to use the affected arm, which is theorized to promote behavioral changes (Taub et al., 2002). The trial-and-error process, accompanied by a sense of agency, was identified as a key aspect of using robotics during occupational therapy. Our research suggests that behavioral changes, represented by occupational performance and participation in desired occupations, occurred in both physical and psychological aspects when making optimal use of robotics, which enhanced the philosophical assumptions of occupational therapists (Gage & Polatajko, 1994). Accordingly, robotics can enhance occupational therapy practice on the basis of existing theory regarding stroke rehabilitation.
Our study characterized the perspectives of occupational therapists using robotics in their clinical practice regarding a wide range of issues. Although outcome measures for robot-assisted therapy are usually classified into International Classification of Functioning, Disability and Health (World Health Organization, 2001) domains (Sivan et al., 2011), our research described occupational therapists’ perspectives of using robotics as a tool for enhancing clinical outcomes, such as body function, occupational performance, and participation in desired occupations. Future research focusing on the perspectives of occupational therapists will provide new information demonstrating the ingenuity of the profession.
Limitations
The results of this qualitative study represent the perceptions of occupational therapists in a single country regarding their experiences with one specific robotic system for stroke rehabilitation. The applicability of robotic therapy is likely to be affected by the health care system in each country and by occupational therapy preferences based on local cultures. Thus, readers should consider differences in cultural background and health care systems, which may limit the applicability of our results to their practice setting. In addition, expectations based on our past experiences may have influenced our findings. To address this limitation, we used strategies to improve trustworthiness, including obtaining feedback from a researcher with no prior experience using robotics, thereby minimizing positive bias.
Implications for Occupational Therapy Practice
The findings from this study have the following implications for occupational therapy practice: Occupational therapists can use robotics as a way to improve patients’ body function and promote the desire for independence. The role of occupational therapists in robotic therapy is to adjust the degree of difficulty to match each patient’s individual body function and goal settings, which enhances clinical outcomes of occupational therapy practice. By understanding current occupational therapy rehabilitation theory and making the best use of robotics, occupational therapists can promote not only improved body function but also higher occupational performance and participation in desired occupations.
Conclusion
This exploratory qualitative study provides new insights into perceptions of the mechanisms and outcomes of occupational therapy using robotics. Occupational therapists regarded robotics as an adjunct to other therapy that improves patients’ body function and promotes their desire for independence. In analyzing their perceptions, we noted novel findings regarding the clinical usability of robotics in occupational therapy. Our results highlighted the ingenuity of occupational therapy as a profession in using robotics.
Footnotes
Acknowledgments
The authors confirm that there are no conflicts of interest to report. We express our deepest gratitude to all the participants for their time and contributions.