The Design Journal An International Journal for All Aspects of Design ISSN: 1460-6925 (Print) 1756-3062 (Online) Journal homepage: http://www.tandfonline.com/loi/rfdj20 Limited Use Only: Exploring the Design of Everyday Objects for Upper Limb Stroke Rehabilitation Mailin Lemke To cite this article: Mailin Lemke (2017) Limited Use Only: Exploring the Design of Everyday Objects for Upper Limb Stroke Rehabilitation, The Design Journal, 20:6, 879-887, DOI: 10.1080/14606925.2017.1371931 To link to this article: http://dx.doi.org/10.1080/14606925.2017.1371931 Published online: 14 Sep 2017. Submit your article to this journal Article views: 7 View related articles View Crossmark data Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=rfdj20 Download by: [UNIVERSITY OF ADELAIDE LIBRARIES] Date: 25 October 2017, At: 06:59 VOLUME 20, ISSUE 6 PP 879–887 REPRINTS AVAILABLE DIRECTLY FROM THE PUBLISHERS PHOTOCOPYING PERMITTED BY LICENSE ONLY © 2017 INFORMA UK LIMITED, TRADING AS TAYLOR & FRANCIS GROUP PRINTED IN THE UK Limited Use Only: Exploring the Design of Everyday Objects for Upper Limb Stroke Rehabilitation Mailin Lemke Victoria University of Wellington, Wellington, New Zealand OVERVIEW Stroke causes significant damage to the brain. Symptoms commonly affect one or both limbs on one side of the body. The preferential use of the less affected limb is called compensatory m ovement and it is a common phenomenon after a stroke, leading to learned non-use of the affected side. The aim of this study was to design everyday objects that can be used by chronic stroke survivors to initiate the use of the arm on the affected side to overcome learned non-use. Following a human-centred design approach, an understanding of the users’ needs was developed and different design solutions were produced and evaluated by stroke survivors and health professionals. Initial findings suggest that the The Design Journal DOI: 10.1080/14606925.2017.1371931 PHD STUDY REPORT 879 Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 THE DESIGN JOURNAL Mailin Lemke object should remind the user to use the affected arm, and the movement needs to take account of the mental model that the user has of the object. KEYWORDS: stroke rehabilitation, research through design, initiation of use, learned non-use, chronic stroke patients, human-centred design, iterative design, design theory Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 Main Report 880 The Design Journal Background Stroke is a form of brain injury that is caused by lack of blood flow or oxygen delivery to the brain, causing irreversible injury to parts of the brain. It affects approximately 15 million people worldwide per year, causing the deaths of one third, while another one third survives with persistent disabilities (McKay and Mensah 2004). Survivors can experience unilateral motor impairment in the form of hemiparesis (weakened muscles) or hemiplegia (paralysis of muscles) (Colman 2009), which impacts on the ability to perform everyday tasks such as dressing or preparing food (Berzina et al. 2013; ICF Research Branch 2013). The concept of spontaneous neurological recovery (Gresham 1986) suggests that regardless of type of stroke and amount of stroke rehabilitation, the main recovery occurs within the first months (Kwakkel, Kollen, and Twisk 2006), leading to an eventual plateau in the recovery process (Kwakkel, Kollen, and Lindeman 2004). Rehabilitation primarily focuses on the first months post stroke, often leaving chronic stroke survivors and caregivers frustrated by the focus of resources on inpatient rehabilitation (Teasell et al. 2012). In particular, chronic stroke survivors with mild impairments are expected to be fully recovered but feel that they cannot live up to those expectations (Carlsson, Möller, and Blomstrand 2004). Improvements in motor impairment need to be differentiated between true recovery and recovery of function (Zarahn et al. 2011). Recovery of function can be due to compensatory movement, which increases functional outcomes in the short term – such as lifting a glass by using extensive trunk movement. However, tasks are often accomplished with abnormal movement patterns and can cause problems in the long term (Cirstea and Levin 2007) and eventually lead to learned non-use of the affected arm (Taub et al. 2006). Learned non-use can be overcome by applying a physical restraint on the less affected arm to restrict its use (MacKenzie and Viana 2016). Although there seems to be a correlation between failed attempts to carry out movement and functional decline (Dancause, Nadeau, and Rossignol 2015), studies have put little focus on the concept of learned non-use and factors that influence it (Andrews and Steward 1979; Sterr, Freivogel and Schmalohr 2002; Stewart and Cramer 2013). Limited Use Only With the trend of moving from hospital to home-based healthcare and rehabilitation, there is a need for systems that are able to deliver self-directed upper limb stroke rehabilitation. Everyday objects for stroke survivors are mainly designed in a way to compensate for the loss of functionality rather than contributing to the rehabilitation process. Our research questions address a current gap in research relating to the use of everyday objects within the rehabilitation process: 1. How can an everyday object that chronic stroke survivors use in activities of daily living restrain movement of the unaffected upper limb to initiate use of the affected arm and hand? The theoretical perspectives, methodologies, and methods are based on constructivist epistemology (Crotty 1998) using a mixed methods approach, which takes account of my subjective role as a researcher in the process of designing objects and evaluating them with participants. The following research questions have been defined to addressed the main research question: 1.1. How can the movement of the upper limb be restrained during rehabilitation to initiate use of the affected arm and hand in chronic stroke patients? 1.2. Which everyday objects are used by stroke survivors during activities of daily living that they like to take part in, and therefore may assist in facilitating use of the affected arm? 1.3. How can an everyday object that stroke survivors use during activities of daily living restrain movement to initiate the use of the affected arm and hand? Results Interviews with Health Professionals 1.1. How can the movement of the upper limb be restrained during rehabilitation to initiate use of the affected arm and hand in chronic stroke patients? Results were analysed using thematic analysis in a deductive manner (Braun and Clarke 2006), and indicated that a physical restraint is mainly used as part of constraint-induced movement therapy (CIMT) in the form of a soft mitt that is worn on the less affected side. However, The Design Journal Thirteen semi-structured interviews with stroke therapists and researchers focusing on stroke rehabilitation were conducted to address the following question: 881 Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 Research Aim and Questions Mailin Lemke Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 the restraint would remind the patient rather than physically constrain the movement. It was emphasized that the patient must undergo behaviour change to overcome the learned non-use, and that selfefficacy is an important component of the process. Research focusing on the development of learned non-use as well as effective selfefficacy elements in terms of upper limb stroke rehabilitation is still scarce. Based on the results of the analysis of the semi-structured interviews, a set of seven design criteria was developed. The design criteria were based on important aspects that the therapists pointed to in regard to the general structure of upper limb stroke rehabilitation as well as specific elements that are used to address the learned nonuse of the upper limb. The set was referred to during the process of designing an everyday object that restrains the movement of the less affected arm in order to evoke an initiation of the affected one. Online Survey with Chronic Stroke Survivors The second question was addressed with an online survey distributed through stroke support platforms. 1.2. Which everyday objects are used by stroke survivors during activities of daily living that they like to take part in, and therefore may assist in facilitating use of the affected arm? One hundred and forty-two participants (male n=66, female n=76), with an average age of 58 years (18–87 years), responded to the survey. Most of the participants lived at home (n=137), and had reached the chronic stage of stroke (n=132). Results were analysed using thematic analysis (Braun and Clarke 2006) and categorized according to themes of activity and participation that are outlined as part of the international classification of functioning (ICF) model. Results indicate that leisure tasks are important before and after the stroke and that telecommunication devices such as computers, cell phones, or tablets play an important role in everyday activities. However, it needs to be considered that these objects are used within a diverse range of activities of daily living, such as being part of a job or to maintain personal relationships. 882 The Design Journal Physical Design Prototypes and Design Method Cards To address the third question, a research through design methodology by ‘conceptualizing research done by means of the skilful practice of design activity revealing research insights’ (Krogh, Markussen, and Bang 2015, 41) was chosen. 1.3. How can an everyday object that stroke survivors use during activities of daily living restrain movement to initiate the use of the affected arm and hand? Serial design experiments (Krogh, Markussen, and Bang 2015) were carried out to investigate how everyday objects can incorporate a rehabilitative purpose. Learning outcomes needed to be articulated in order to justify decisions that were made during the process (Ehn and Ullmark 2017). Further clarification was needed as to how the design would map the problem domain and the theoretical solutions (Haynes and Carroll 2007). This mapping was considered in the summary of findings that influenced further developments, and through testing design prototypes in the form of an interactive radio (see Figure 1) with stroke survivors. Interactive Radio The first design prototype is an interactive radio that restrains the movement to a specific arm. The radio was chosen based on the home skill assignment list stating numerous tasks that stroke patients could focus on in a self-directed way as part of their home-based training. The formative usability evaluation of the radio (see Figure 1) indicated that reminding rather than restraining the user might be beneficial and that the movement the object intends to evoke needs to take account of the mental model that the user has of the object. However, the functionality of a radio that was focused on in the first design prototype evoked mixed responses. Digital Design Method Cards A conceptual framework (Gaver 2012), in the form of digital method cards that offer many design approaches, was developed for other designers to refer to when designing objects for stroke survivors. The strategies were based on a design workshop with industrial design students investigating different ways of restraining the movement and evoking a behaviour change in the user. The digital method cards were The Design Journal Figure 1. Design prototype tested by chronic stroke survivors. 883 Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 Limited Use Only Mailin Lemke Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 Figure 2. Website with digital method cards tested by designers. incorporated into a website, which explains important facts about stroke and the impact it has on the individual in order to develop empathy in the designer. The set of eight design approaches and examples of everyday objects that were developed as part of a workshop are included to guide the design process of designing objects with a rehabilitative purpose (see Figure 2). Initial findings suggest that the design strategies help produce objects with a rehabilitative purpose and offer guidance in the design process. Future Research 884 The Design Journal The next iteration of the design prototypes could be based on our survey results indicating that devices used as part of telecommunication, such as computers or cell phones, are important objects in the lives of chronic stroke survivors. Aesthetic attributes and symbolic meaning might influence the integration of a rehabilitation object into the stroke survivor’s home environment and could be focused on in further studies. Acknowledgements I would like to thank my supervisors, Dr Edgar Rodríguez Ramírez from the School of Design at Victoria University of Wellington, and Dr Brian Robinson from the Graduate School of Nursing, Midwifery and Health at Victoria University of Wellington, whose input and support made this research possible. I would further like to thank the therapists, stroke survivors, design students and designers who participated in this research and provided Limited Use Only critical and valuable insights into the rehabilitation process and usability of the design concepts as well as into relevant strategies. Disclosure Statement No potential conflict of interest was reported by the author. This research is funded by the Victoria Doctoral Scholarship Fund. Additional funding is provided by the Centre of Research Excellence in Medical Technologies New Zealand. Andrews, Keith, and Jean Steward. 1979. “Stroke Recovery: He Can but Does He?” Rheumatology 18 (1): 43–48. Berzina, Guna, Markuu Paanalahti, Åsa Lundgren-Nilsson, and Katharina S. Sunnerhagen. 2013. “Exploration of Some Personal Factors with the International Classification of Functioning, Disability and Health Core sets for stroke.” Journal of Rehabilitation Medicine 45 (7): 609–615. Braun, Virginia, and Victoria Clarke. 2006. “Using Thematic Analysis in Psychology.” Qualitative Research in Psychology 3 (2): 77–101. doi:10.1191/1478088706qp063oa. Carlsson, Gunnel, Anders Möller, and Christian Blomstrand. 2004. “A Qualitative Study of the Consequences of ‘Hidden Dysfunctions’ One Year after a Mild Stroke in Persons < 75 Years.” Disability and Rehabilitation 26 (23): 1373–1380. Cirstea, M. C., and M. F. Levin. 2007. “Improvement of Arm Movement Patterns and Endpoint Control Depends on Type of Feedback During Practice in Stroke Survivors.” Neurorehabilitation and Neural Repair 21 (5): 398–411. Colman, Andrew M. 2009. A Dictionary of Psychology. Oxford: Oxford University Press. http://www.oxfordreference.com/views/BOOK_ SEARCH.html?book=t87. Crotty, Michael. 1998. The Foundations of Social Research: Meaning and Perspective in the Research Process. London; Thousand Oaks, Calif: Sage Publications. Dancause, Numa, Sylvie Nadeau, and Serge Rossignol, eds. 2015. Sensorimotor Rehabilitation: At the Crossroads of Basic and Clinical Sciences. Progress in Brain Research 218. Amsterdam: Elsevier. Ehn, Pelle, and Peter Ullmark. 2017. “Educating the Reflective Design Researcher.” In Practice Based Design Research, edited by Laurene Vaughan, 77–86. New York: Bloomsbury Academic. Gaver, William. 2012. “What Should We Expect from Research through Design?” In Proceedings of the SIGCHI Conference on Human Factors in Computing Systems, 937–946. Austin, Texas: ACM. The Design Journal References 885 Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 Funding 886 The Design Journal Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 Mailin Lemke Gresham, G. E. 1986. “Stroke Outcome Research.” Stroke; a Journal of Cerebral Circulation 17 (3): 358–360. Haynes, Steven R., and John M. Carroll. 2007. “Theoretical Design Science in Human–Computer Interaction: A Practical Concern?” Artifact 1 (3): 159–171. ICF Research Branch. 2013. “Comprehensive ICF Core Set for Stroke”. Comprehensive ICF Core Set for Stroke. http://www.icf-researchbranch.org/download/send/12-cardiovascularandrespiratoryconditions/199-comprehensive-icf-core-set-stroke. Krogh, Peter Gall, Thomas Markussen, and Anne Louise Bang. 2015. “Ways of Drifting – Five Methods of Experimentation in Research Through Design”. In ICoRD’15 – Research into Design Across Boundaries Volume 1, edited by Amaresh Chakrabarti, 34, 39–50. New Delhi: Springer India. doi:10.1007/978-81-322-2232-3_4. Kwakkel, Gert, Boudewijn Kollen, and Eline Lindeman. 2004. “Understanding the Pattern of Functional Recovery after Stroke: Facts and Theories.” Restorative Neurology and Neuroscience 22 (3–5): 281–299. Kwakkel, G., B. Kollen, and J. Twisk. 2006. “Impact of Time on Improvement of Outcome After Stroke.” Stroke 37 (9): 2348–2353. MacKenzie, Heather M., and Ricardo Viana. 2016. “Constraint-Induced Therapies.” In Ischemic Stroke Therapeutics, edited by Bruce Ovbiagele, 217–223. Cham: Springer International Publishing. https:// link.springer.com/10.1007/978-3-319-17750-2_21. McKay, Judith, and George A. Mensah. 2004. The Atlas of Heart Disease and Stroke. Geneva: World Health Organization. Sterr, Annette, Susanna Freivogel, and Dieter Schmalohr. 2002. “Neurobehavioral Aspects of Recovery: Assessment of the Learned Nonuse Phenomenon in Hemiparetic Adolescents.” Archives of Physical Medicine and Rehabilitation 83 (12): 1726–31. doi:10.1053/ apmr.2002.35660. Stewart, J. C., and S. C. Cramer. 2013. “Patient-Reported Measures Provide Unique Insights Into Motor Function After Stroke.” Stroke 44 (4): 1111–1116. Taub, E., G. Uswatte, V. W. Mark, and D. M. M. Morris. 2006. “The Learned Nonuse Phenomenon: Implications for Rehabilitation.” Europa Medicophysica 42 (3): 241–256. Teasell, Robert, Swati Mehta, Shelialah Pereira, Amanda McIntyre, Shannon Janzen, Laura Allen, Liane Lobo, and Ricardo Viana. 2012. “Time to Rethink Long-Term Rehabilitation Management of Stroke Patients.” Topics in Stroke Rehabilitation 19 (6): 457–462. Zarahn, E., L. Alon, S. L. Ryan, R. M. Lazar, M.-S. Vry, C. Weiller, R. S. Marshall, and J. W. Krakauer. 2011. “Prediction of Motor Recovery Using Initial Impairment and fMRI 48 h Poststroke.” Cerebral Cortex 21 (12): 2712–2721. Limited Use Only Biography Address for Correspondence The Design Journal Mailin Lemke, Victoria University of Wellington, School of Design, 139 Vivian Street, Te Aro, 6011 Wellington, New Zealand. Email: firstname.lastname@example.org 887 Downloaded by [UNIVERSITY OF ADELAIDE LIBRARIES] at 06:59 25 October 2017 Mailin Lemke has a degree in scenography and graphic design from the University of Applied Sciences in Dortmund, followed by an MA in ‘Communication in space’ from the University of Applied Sciences in Mainz. She worked as an interface and graphic designer at the design studio ‘dreiform’ in Cologne, and enrolled in 2015 in a PhD programme focusing on medical device design at Victoria University of Wellington, New Zealand.