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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.
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Date: 25 October 2017, At: 06:59
VOLUME 20, ISSUE 6
PP 879–887
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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
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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
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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:
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Research Aim and Questions
Mailin Lemke
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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.
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Limited Use Only
Mailin Lemke
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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.
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The Design Journal
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Mailin Lemke
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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: mailin.lemke@vuw.ac.nz
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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.
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