Stroke patients' utilisation of extrinsic feedback from computer-based technology in the home.

Background: Evidence indicates that post-stroke rehabilitation improves function, independence and quality of life. A key aspect of rehabilitation is the provision of appropriate information and feedback to the learner.Advances in information technology (IT) have allowed for the development of various systems to complement stroke rehabilitation that could be used in the home setting. In the near future these systems may increase the provision of rehabilitation a stroke survivor receives and carries out, as well as providing a learning platform that facilitates long-term self-management.Aim: To explore the utilisation of extrinsic feedback from computer-based technology to facilitate post-stroke upper-limb rehabilitation in the home.Method: Using the principles of realistic evaluation, this study explored the context of utilising computer feedback for upper limb stroke rehabilitation in the home setting; the underpinning theory-driven mechanisms of the intervention and how these impacted on theoretical outcomes. Focus groups with Community Stroke Teams were followed by initial testing and multi-method case studies before, during and after the use of computer-based equipment. Data were analysed in relation to the hypotheses case by case. This was followed by a synthesis of the findings to answer the question, 'what works for whom and in what circumstances and respects?' Findings: Data analysis reveals that in order to achieve desired outcomes through the use of computer technology, key elements of computer-feedback such as; accurate, measurable, rewarding, adaptable, and knowledge of results feedback are required to trigger the mechanisms underpinning the intervention. In addition, the pre-existing context and the personal and environmental contexts such as; previous experiences of service delivery, personal goals, trust in technology, social circumstances and practicalities may also enable or constrain the underpinning theory-driven mechanisms. Discussion: This research has explored the implications of the paradigm shift from therapist led rehabilitation where feedback is provided face-to-face to a more patient led model of rehabilitation where feedback is provided by a computer in the absence of a therapist. Findings suggest that the delivery of feedback in clinical practice is led by their empirical knowledge and understanding of the therapists. However, this model of delivery may not be conducive to motor learning and self-management and may also influence the personal context of users.The theory-driven mechanisms underpinning the utilisation of feedback from computer-based technology for home-based upper-limb post-stroke rehabilitation are dependent on key elements of computer feedback and the personal and environmental context. The discovery of these elements may therefore result in the development of technology; therapy education and the subsequent adoption of technology and a self-management paradigm; long-term self-managed rehabilitation; and importantly, improvements in the physical and psychosocial aspects of recovery. Further work is required to; develop the technology so that it incorporates the elements of feedback highlighted by this research; ensure the technology is robust, reliable and accurate; investigate the clinical utility of technology for home-based stroke rehabilitation, and the extent to which it might encourage utilisation by the end user.