J Rehabil Med 2020; 52: jrm0000X

ORIGINAL REPORT

FACTORS AFFECTING THE USABILITY OF AN ASSISTIVE SOFT ROBOTIC GLOVE

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AFTER STROKE OR MULTIPLE SCLEROSIS

Susanne PALMCRANTZ, PT, PhD, Jeanette PLANTIN, PT, MSc and Jörgen BORG, MD, PhD
From the Karolinska Institutet, Department of Clinical Sciences, Danderyd Hospital, Division of Rehabilitation Medicine, Stockholm, Sweden
Journal of Rehabilitation Medicine

Objective: To explore the usability and effects of an LAY ABSTRACT

assistive soft robotic glove in the home setting after To explore factors impacting on the usability of an as-
stroke or multiple sclerosis. sistive soft robotic glove in the home setting after stroke
Design: A mixed methods design. or multiple sclerosis. Twenty participants living with the
Methods: Participants with stroke (n =  10) or multi- effects of stroke or multiple sclerosis used the assistive
ple sclerosis (n =  10) were clinically assessed, and glove in the home for 6 weeks. Perceived usability was
instructed to use the glove in activities of daily living reported in weekly telephone interviews and one semi-
for 6 weeks. They reported their experience of using structured interview. Functioning was clinically assessed.
the glove via weekly telephone interviews and one Perceived beneficial effects were a sustained and strong
semi-structured interview. grip. Reported disadvantages were a lack of assistance
Results: The soft robotic glove was used by partici- in opening the hand, lack of wrist support, and the glove
pants in a wide variety of activities of daily living. not being usable for fine hand use. The glove was found
Perceived beneficial effects while using the glove to be useful mainly by participants with moderate limita-
were a sustained and a strong grip. Disadvantages tions in hand activity and an overall level of functioning
of using the glove were a lack of assistance in hand that allowed participation in everyday life activities. This
opening function and the glove not being usable for study identified a subgroup of participants, who found
fine hand use. The glove was found to be useful by the glove useful in activities requiring a strong and pro-
two-thirds of participants who completed the study, longed grip but not for fine hand use, and highlights as-
mainly by participants with moderate limitations in pects for consideration in the further development of soft
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hand activity and an overall level of functioning that hand robotics for sustained use in a larger population
allowed participation in everyday life activities. living with a central nervous system lesion.
Conclusion: This study identified a subgroup of par-
ticipants, who found the glove useful in activities re- cific rehabilitation interventions, e.g. constraint-induced
quiring a strong and prolonged grip but not fine hand movement therapy (CIMT), may improve hand function
use, and highlights aspects for consideration in the
after stroke (8), many patients are left with impaired
further development of soft hand robotics for sustai-
hand motor function that limits their everyday activities
ned use in a larger population living with a central
and restricts participation in work and other social life.
Journal of Rehabilitation Medicine

nervous system lesion.

The estimated prevalence of MS in Sweden is 17,500
Key words: robotics; assistive technology; stroke; multiple (4) and upper extremity function is impaired in a ma-
sclerosis; evaluation; qualitative; quantitative. jority of patients. Johansson et al. reported difficulties
Accepted Jan 16, 2020; Epub ahead of print Jan 29, 2020 with manual dexterity in up to 79% of 219 patients (5)
and Cano et al. reported that 51% out of 285 patients
J Rehabil Med 2020; 52: jrm000XX
experienced at least moderate impairments in hand fun-
Correspondence address: Susanne Palmcrantz, University Department ction, impacting on activity performance, leaving only
of Rehabilitation Medicine, Danderyd Hospital, Stockholm, SE- 182 88
Sweden. E-mail: [email protected] 20% who reported no limitations or restrictions (9).
Therefore, there is a need for new, innovative and
individually designed interventions to improve function,

S troke and multiple sclerosis (MS) are neurologi-

cal conditions that commonly cause upper limb
impairment, long-term disability and dependence in
through restorative treatments or by use of compensatory
strategies and assistive devices, in many people with
prior stroke or MS. Currently, numerous supportive
activities of daily living (ADL) worldwide (1–5). tools, including various orthoses, are used for static
The annual incidence rate of stroke in Sweden is ap- support of, for example, the wrist. New technologies
proximately 300 per 100,000 inhabitants (6) and a majo- aiming to improve manual activity performance are in
rity of stroke survivors experience impaired function in various stages of development, but, to date, evidence
the upper limb and hand (7). Recovery of hand function demonstrating the effects of a device that improves
after stroke is, therefore, crucial and is one of the major hand motor function in everyday life has been scarce.
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goals of rehabilitation. However, only approximately During the last decade, various electromechanical and
50% of stroke patients with initial arm paresis regain robot-assisted devices for arm and hand training have
full function (7). Despite increasing evidence that spe- been developed and tested, although the quality of the

This is an open access article under the CC BY-NC license. www.medicaljournals.se/jrm

Journal Compilation © 2020 Foundation of Rehabilitation Information. ISSN 1650-1977 doi: 10.2340/16501977-2650
 p. 2 of 12 S. Palmcrantz et al.
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rehabilitation clinics in Stockholm County, Sweden. Recruitment

was administered by the Division of Rehabilitation Medicine at
Danderyd Hospital. Study information was distributed to physioth-
erapists and made available to patients at the clinics. Information
was also made available to people with stroke or MS who were
visiting exhibitions for assistive devices, including the SEM Glove.
Eligible for inclusion were people with stroke (> 6 months
since onset) or MS (stable condition > 6 months) and perceived
Journal of Rehabilitation Medicine

limitations in ADL due to impaired hand function. A minimum

Fig. 1. Motor performance with the SEM glove. The SEM glove provides
of visible activation of the wrist and finger extensor muscles
actuation for the thumb, middle and ring fingers. The applied force is was required. In addition, participants were required to be
measured by pressure sensitive sensors at the tip of the fingers of the able to handle the SEM Glove with or without support from a
glove and is regulated by the pull of thin lines that run through a cord significant other or a personal assistant.
and attach to the motors. A case that can be worn at the waist or in a Exclusion criteria were: severe speech and language or cogni-
bag includes the motors, computer, batteries and controller (reproduced tive impairments preventing informed consent or understanding
with permission from Bioservo Technologies Inc). and complying with study instructions; other diseases that might
affect hand function; other somatic or psychiatric conditions or
evidence regarding potential effects is still limited (10). drug abuse that may interfere with study participation; ongoing
rehabilitation intervention or participation in another clinical
Most robotic systems are relatively heavy and stiff, but study that might have an impact on hand function; and treatment
current developers have produced more lightweight and with intramuscular injections of Botulinum toxin within less
flexible solutions (11–13). One is a new glove, based on than 3 months prior to study start
Robotic SEM™ Technology (14) (Fig. 1), which offers
the possibility of increasing grip strength for patients Data collection
with impaired hand function. The SEM™ Glove device A mixed methods design was used (17). Quantitative data were
is designed to be slim, lightweight, neat, comfortable, collected before the intervention and qualitative data during and
and is intended to be worn as a glove. The technology after the intervention. Sociodemographic data included age, sex,
concept goes beyond other state-of-the-art devices by current occupation, civil/cohabitant status, time since stroke/
time since MS diagnosis. The modified Rankin Scale (mRS) was
introducing an “intention detection” logic that activates used to categorize the level of overall functioning and a cut-off
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support if, and only if, the wearer initiates movement for disability was set at mRS >  1 point (where 1 = no significant
with a natural movement intention. This is achieved disability despite symptoms; able to carry out all usual duties
by sensors on the fingertips that detect minimal pressure and activities) (18, 19); the Barthel Index (BI) (20) was used to
changes initiated by the wearer, which are transferred assess degree of independence and a cut-off for independence
was set at BI ≥  95 points (21).
to actuators. These respond immediately in order to Standardized measures of body function of the upper limb
facilitate the intended movement. included the active range of wrist movement assessed with a
Experiences with the SEM Glove in patients with goniometer and grip strength by use of a digital hand dyna-
impaired hand function, but some retained extensor mometer (www.Saehan.com) with a cut-off for impairment
Journal of Rehabilitation Medicine

function in the fingers, suggest that it may support set based on adult norms (women < 22 kg right and < 20 kg
left and men <  37 kg right and < 35 kg left) (22). Furthermore,
hand function and increase independence in everyday somatosensory function (touch and proprioception), passive
activities (15; and unpublished data). However, data movement and pain was assessed with the Fugl-Meyer sub-
on the feasibility of the SEM Glove for use by patients scales (23); spasticity with the Modified Ashworth scale (24),
with impaired hand function due to central paresis are and the neural component of resistance to passive stretch was
scarce. Recently, observations were reported on the quantified by use of the NeuroFlexor method (25–27). A neural
component > 3.4 Newton (N) was considered as hand spasticity
feasibility of the SEM Glove in a group of 5 patients (28). Gross manual dexterity was assessed with the Box and
in the chronic phase after stroke (16), but more data Block Test (BBT), and impairment level was set based on adult
are needed to guide the clinical application and further norms (women < 66 blocks right and < 64 blocks left and men
development of this glove. The primary aim of this < 63 blocks right and < 68 blocks left) (29). The ability to move
study was therefore to determine what factors affect and handle objects was assessed by use of the Action Research
Arm Test (ARAT) (30).
the usability of the assistive SEM Glove when used in Qualitative data for everyday activity performance and per-
the home setting after stroke or MS, in relation to diag- ceptions of using the SEM Glove were collected via weekly
nosis, functioning, disability and perceived usability. structured telephone interviews conducted by the same phy-
siotherapist who performed the clinical assessments and fitted
the SEM Glove. The interview included questions related to
METHODS overall use of the SEM Glove and specified activities, as well
as advantages and disadvantages experienced when using the
glove, including adverse events. At the end of the intervention,
Study participants
participants were asked to report their experiences in a semi-
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Participants aged 18 years or older with impaired hand function structured interview performed by an experienced therapist not
after stroke (n = 10) or MS (n = 10) were recruited from outpatient otherwise involved in the study. The interview guide included

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Table I. Characteristics of the included participants Functioning, Disability and Health (ICF) (31). The interviews
Stroke n = 10 MS n = 10 were digitally recorded and transcribed verbatim. Qualitative
content analysis was used for analysis (32). The texts were read
Age, years, mean (SD) [range] 61 (13) [40–83] 56 (8)
[47–70] through carefully, condensed to meaningful units and coded into
Women/men, n 2/8 7/3 subcategories and categories. The subcategories and categories
Time since diagnosis of MS, months (SD) 217 (72) were critically examined to secure trustworthiness. To allow
[range] [133–330]
analysis of potential differences in perceived usability related
Time since stroke onset, months (SD) [range] 16 (11) [7–41]
to diagnosis, subcategories were labelled with the informants’
Journal of Rehabilitation Medicine

Overall disability and dependence, mRS > 1 p, n 10 10

Working*/sickness benefit/retired, n 1/6/3 3/4/3 diagnoses. To explore how diagnosis and level of functioning
Cohabiting/living alone, n 1/9 7/3 and disability were related to perceived usability, quantitative
Hand fitted with glove dominant/non-dominant, n 7/3 4/6 and qualitative data were merged by tabulating the patient’s level
*Part-time. of functioning and disability combined with their response to a
SD: standard deviation, mRS: modified Rankin Scale; MS: multiple sclerosis. question posed in the semi-structured interview related to the
experienced usability of the glove.
questions related to perceived usability of the glove in ADL and
potential effects on hand function and/or activity. RESULTS

Intervention procedure Participants’ characteristics

The SEM Glove was fitted on the hand perceived as being impai- Characteristics of the included participants (stroke
red by the participant and identified as being impaired by the phy- n = 10, MS n = 10) are shown in Table I. Occurrence
siotherapist, based on the initial assessments. The physiotherapist of activity limitations and impairments in the upper
had been trained in this procedure by a specialist from the SEM
Glove manufacturer (Bioservo Technologies Inc, Stockholm,
extremity of the gloved hand are shown in Table II.
Sweden). The fitting included settings for power transferred by Except for a lower BI score and grip strength among
the tendons and sensitivity of the sensors for each finger. More- participants with MS, activity limitations and impair-
over, the participant was educated in donning and doffing the ments in the upper extremity were in a similar range
glove, changing the batteries, and given written instructions on in the diagnostic groups (Table II). Furthermore, 2
the functioning of the glove. The participant was instructed to
use the glove in ADL, on a daily basis, for a period of 6 weeks.
participants in the stroke group and MS group, respec-
tively, could actively extend their wrist, but not above
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0° against gravity, and 5 participants in the stroke

Ethical approval
group and 3 participants in the MS group could not
The study was approved by the Regional Ethical Review Board fully extend all fingers against gravity.
in Stockholm (2016/980-31/1).
Experiences of using the SEM Glove in activities of
Data analyses daily living
A mixed methods embedded design was used (17). Descriptive
Participant’s contributions to the study are shown in
Journal of Rehabilitation Medicine

statistics were used for quantitative data. Information regarding

activities in which the SEM Glove had been used was grouped Fig. 2. Of the 20 included participants, 19 shared their
according to diagnosis and the International Classification of experiences of using the SEM Glove in ADL in weekly

Table II. Results of assessments of activity limitations and impairments in the upper extremity of the gloved hand
Stroke n = 10 Stroke n = 10 MS n = 10 MS n = 10
Method of assessment and indicated limitation or impairment level Median (IQR) Impaired/Limited, n Median (IQR) Impaired/Limited, n
Dependence in mobility and/or personal care, Barthel Index < 95 p 95.0 (13.75) 4 42.5 (56.25) 9
Grasp, ARAT< 18 points 12.0 (1.00) 10 12.5 (5.75) 9
Grip, ARAT< 12 points 8.0 (2.25) 10 8.0 (3.75) 9
Pinch, ARAT< 18 points 8.0 (10.25) 10 10.0 (6.75) 10
Gross movement, ARAT< 9 points 6.0 (1.25) 10 6.0 (2.00) 8
Total score ARAT< 57 points 33.5 (14.00) 10 36.5 (15.25) 10
Manual dexterity, Box and block test women < 64–66 blocks, men 20.0 (32.25) 10 27.5 (7.50) 10
< 63–68 blocks*
Passive movement, Fugl-Meyer upper extremity < 24 points 19.5 (6.25) 7 22.5 (3.25) 8
Pain, Fugl-Meyer upper extremity < 24 points 22.5 (2.5) 6 24.0 (1.25) 4
Sensory function, Fugl-Meyer upper extremity < 12 points 12.0 (7.25) 4 10.0 (1.5) 8
Grip strength, Dynamometer, women < 20–22 kg, men < 35–37 kg* 19.5 (6.25) 10 7.4 (7.98) 9
Spasticity, Ashworth internal rotators, biceps, triceps, supinators and/or 8 2
pronators > 0
Spasticity, Ashworth hand and/or finger flexors > 0 8 3
Hand spasticity (neural component, NC> 3,4 N according to NeuroFlexor 2.28 (6.50) 4 0.38 (2.23) 0
assessment)
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A higher score indicates a higher level of functioning. Range: Barthel Index 0–100 p, Action Research Arm Test (ARAT) Grasp 0–18 p, ARAT Grip 0–12 p, ARAT
Pinch 0–18 p, ARAT Gross movement 0–9 p, ARAT Total 0–57 p, Fugl– Meyer Passive movement 0–24 p, Pain 0–24 p and Sensory function 0–10 p, Modified
Ashworth scale (Ashworth) 0–5, Neural Component (NC), adult norm > 3.4 Newton (N).
IQR: interquartile range; MS: multiple sclerosis.

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Included: Stroke n=10 and MS n=10

Withdrew after initial fitting of glove due to perceived

lack of usability (MS n=1)

Shared experiences of using the glove in ADL in standardized telephone

Journal of Rehabilitation Medicine

interviews n= 19 ( Stroke n=10 and MS n=9)

Never started using the SEM Glove due to perceived

lack of usability (Stroke n= 1).

Stopped using SEM Glove after 2 weeks due to

perceived lack of usability (MS n=1).

Stopped using SEM Glove after 2 weeks due to illness,

(Stroke n=1).

Finalised 6 weeks, declined semi structured interview

(MS n=1)

Shared expericences of using the glove in semi structured

interviews n=15 (Stroke n=8 and MS n=7)

Fig. 2. Flow chart of participants’ contribution to the study. MS: multiple sclerosis.

telephone interviews during the intervention (Fig. 2). overall disability or the fact that the need for assistance
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The participants with stroke used the glove for a mean in fine hand use were not met by the glove. Additional
of 4 weeks (standard deviation (SD) 2.1, range 0–6 reasons were related to the construction of the glove,
weeks) as did the participants with MS (mean 4 weeks, which was perceived as bulky and unwieldy, or private
SD 1.8, range 2–6 weeks). One participant with stroke circumstances.
never started using the glove in the home setting and No adverse events were reported, with the exception
was followed up on only one occasion. of one participant in whom the SEM Glove band used
Reasons for not using the SEM Glove for the full to attach the cord to the forearm scratched the skin.
6 weeks among participants in the stroke group were This participant was then instructed to use the glove
Journal of Rehabilitation Medicine

problems with setting the glove, illness, and private only with long-sleeved clothing.
circumstances. In the MS group, reported reasons for Participants’ reported activities chosen to explore
not using the glove in the home were illness, hospi- the usability of the SEM Glove derived in the weekly
talization, not finding suitable activities either due to telephone interviews are shown in Table III and repor-

Table III. Participants’ reported activities chosen to explore the usability of the SEM Glove (multiple sclerosis (MS) n = 9, Stroke n = 10)
Activities of daily living
ICF domains Stroke Multiple sclerosis

Acquisition of goods and services Shopping for groceries Shopping for groceries
Preparing meals Holding, lifting, manipulating and preparing groceries or Holding, lifting, manipulating and preparing groceries,
tableware kitchen utensils or tableware
Doing housework Handling objects related to cleaning, or organizing Handling objects related to cleaning, folding laundry or
household objects organizing household objects
Caring for household objects Gardening, carpentry, installing IT Watering flowers
Changing and maintaining body position Transportation to/from and in wheelchair
Carrying, moving and handling objects Carrying and moving and stabilizing objects of various Carrying and moving furniture, sawn goods, books or
sizes and weights glassware
Walking and moving Walking and holding a crutch Walking and moving using manual wheelchair, crutches or
a mobility scooter
Self-care Eating and pulling up trouser Eating, drinking, brushing teeth, squeezing tube of skin
cream
Moving around using transportation Holding the steering wheel of the car
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Work and employment Typing on the computer

Recreation and leisure: Typing on the computer, turning pages, writing, Eating out, working out/physical rehabilitation and sports,
photographing, working out/physical rehabilitation using the computer
Other All activities during the day

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Table IV. Participants´ reported beneficial effects and disadvantages of using the SEM glove in activities of daily living (ADL) (multiple
sclerosis (MS) n = 9, stroke n = 10)
Advantages/Disadvantages
Beneficial effects Disadvantages Beneficial effects Disadvantages
Diagnosis Stroke Stroke MS MS
Muscle functions Perceived decreased tone, improved Little finger perceived as Perceived improved strength, Pain/discomfort in shoulder when
strength, grip, coordination that lasts frozen in flexed position range of movement, grip and in use. Perceived as too weak for
Journal of Rehabilitation Medicine

after use. Perceived as a training when using the glove decreased muscle tone that the glove
device lasts after use
General activity level Increased active use of hand Lost the grip. Not Increased spontaneous use
perceived as usable in ADL of hand
Preparing meals Comfortable with lifting and carrying Difficult to use with Can hold, lift manipulate and Want to avoid activities where the
objects in the kitchen. cutlery. Cooking works prepare groceries, pots or glove may get sticky
Works sufficiently to be used for better without glove. tableware
cooking Not usable for holding a
knife for cooking
Doing housework Assistive in cleaning and emptying Can lift flowerpots The glove is too bulky and
dishwasher unreliable when emptying the
dishwasher and too slow for
folding laundry
Caring for household Assistive in gardening and
objects manoeuvring a wheelbarrow
Changing and Improved perceived ability in Good grip but cannot release it
maintaining body rising to standing, in standing during transfer from one seating
position and in transferring from one to the other
seating to the other when
hand support is required
Writing or using The glove hinders The glove hinders typing, using an
communication devices positioning of the hand ipad and mobile phone
and techniques when writing. Cannot write
with glove on
Carrying, moving and Perceived improved ability to use Difficult to handle small Improved perceived ability
handling objects hand with glove to pick up, maintain object in reaching, lifting and
grip and carry and move objects maintaining grip
without worrying about dropping
them. Ability to use gloved hand for
support
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Walking and moving Perceived as easier to grip Perceived as insecure to use

the wheel of the wheelchair the glove when walking with
and improved endurance crutches and walker due to the
while propelling the manual placement of sensors and the
wheelchair plastic component in the palm of
the hand
Self-care Difficult to wear Perceived as easier to Cannot wash hands with glove
underneath some squeeze a tube, hold a on. Complicated to handle the
garments. Clumsy during toothbrush, lift a cup or glove and cord when dressing and
mealtimes drinking bottle and hold a motor unit when visiting toilet. No
banister while transferring assistance while eating due to the
Journal of Rehabilitation Medicine

placement of the sensors

Moving around using Easier to hold steering wheel when
transportation driving
Recreation and leisure Can maintain grip when holding Not aesthetic to wear the Cannot hold a ball due to plastic
handlebar on stationary bike. motor unit when you meet component in the palm of the
Perceived as useful when practicing other people hand
flexion and extension of fingers
Donning and doffing Learned how to put on the
glove oneself.
Other You do not feel the glove after a Getting used to the glove.
while Can be combined with wrist
support

MS: multiple sclerosis; ADL: activities of daily living.

ted advantages and disadvantages of using the glove ADL and 5 did not. Two groups emerged in terms of
in ADL are shown in Table IV. their experience of using the glove in ADL. The first
Fifteen participants (stroke n = 8, MS n = 7) reported group (MS n = 4 and stroke n = 6) included participants
their overall experience of using the SEM Glove in who found the glove to be useful in some ADL and the
semi-structured interviews at the end of the interven- second group (MS n = 3, stroke n = 2) included parti-
tion (Fig. 2). The categories that emerged from the in- cipants who did not find the glove useful in any ADL.
terviews were: body function and activity performance Level of functioning and disability among participants,
in ADL; general activity level in ADL; lasting effects who found the glove usable in ADL, is shown in Ta-
on functioning; level of functioning needed for bene- ble V, and of participants who did not find the glove
ficial effects; learning period; activity performance usable in Table VI, together with reported aspects of
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related to the construction of the glove. Furthermore, usability. The representation of participants with Stroke
10 participants found the glove to be useful in some and MS is presented in brackets throughout the text.

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Table V. Clinical characteristics of the participants who found the glove to be useful in some ADL (n = 10)
Assessment measure and indicated
limitation or impairment level P5 P6 P7 P8 P9 P10 P1 P2 P3 P4
Diagnosis Stroke Stroke Stroke Stroke Stroke Stroke MS MS MS MS
Sex Man Man Man Man Man Man Woman Man Woman Woman
Gloved hand, Non-dominant/Dominant D D Non–D D D Non–D Non–D Non–D Non–D D
Overall disability and dependence, mRS, 3 2 2 2 3 3 4 4 5 4
1–6 points
Dependence in mobility and/or personal 75 95 100 95 100 90 60 45 5 15
care, Barthel Index < 95 points
Grasp, ARAT max < 18 points 7 12 11 13 12 12 5 1 12 16

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Grip, ARAT max < 12 points 6 5 6 8 8 8 4 0 7 7
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Pinch, ARAT max < 18 points 0 0 8 6 9 10 6 0 6 10

Gross movement, ARAT< 9 points 4 6 6 6 5 6 4 0 7 9
Total score ARAT< 57 p 17 23 31 33 34 36 19 1 32 42
Manual dexterity, Box and block test 15 9 10 46 24 22 18 1 26 29
women < 64–66 blocks, men < 63–68
blocks
Sensory function, Fugl-Meyer upper 12 12 12 5 12 10 10 12 8 11
extremity < 12 points
Spasticity, Neuroflexor hand flexors NC 19.81 8.39 2.13 2.43 7.46 6.03 2.03 2.18 –0.89 –0.14
≥ 3.4 N
Spasticity, Ashworth internal rotators, Yes Yes No No Yes Yes No Yes No No
biceps, triceps, supinators and/or
pronators > 0
Spasticity, Ashworth hand and/or Yes Yes No Yes Yes No Yes Yes No No
fingerflexors > 0
Active ROM extension of dig I–V Full Impaired Full Impaired Full Impaired Impaired Impaired Full Full
Grip strength, women < 20–22 kg, men 11 13 18 7 13 12 4 3 8 13
< 35–37 kg
Reported reasons for finding the glove Sustained grip Sustained grip, Sustained grip Stronger Stronger Sustained grip Sustained grip Sustained Sustained Sustained strength
useful enabled bimanual hand hand grip grip throughout the day
activities
Reported reasons for not finding the No assistance Not for fine-hand Not for fine- Plastic Bulky Difficult to don, No assistance in fine No assistance Bulky and No wrist support,
glove useful in releasing use, difficult to hand use, component bulky hand use. Sensor in releasing glove difficult to don,
the grip open hand, bulky difficult to open of glove placement. the grip not usable in plastic component
hand and thumb hindered grip Plastic component of water of glove hindered
glove hindered grip. grip
Heavy and bulky

mRS: modified Rankin Scale; ARAT: Action Research Arm Test; NC: Neural Component; N: Newton; MAS: Modified Ashworth Scale; ROM: range of motion; dig: digitorum; MS: multiple sclerosis; ADL: activities of daily living.
 Usability of an assistive soft robotic glove p. 7 of 12

Body function and activity performance in ADL among found to be useful (MS, stroke). The glove enabled
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participants who found the SEM Glove useful in ADL these participants to produce more power and to hold
and sustain the grip during training (MS, stroke).
The SEM Glove enabled participants to produce more
“No, I didn’t get the hang of it in the way I wanted to…..
power and to hold and sustain the grip (MS and stroke),
So, then, I´ve seen it more as a training… device rather than
as well as improving the quality of the grip, which assistance in ADL existence.”
enabled handling and holding household objects (MS
Journal of Rehabilitation Medicine

and stroke). General activity level in ADL among participants

“The benefit has been that I have been able to use my left
who found the SEM Glove useful in ADL
hand to lift things up and grasp things. Well, first grasp and
then lift…. couldn’t before.” One reflection made by participants who were depen-
Moreover, the SEM Glove was reported to enable dent as regards ADL, was that they performed ADL
the use of the gloved hand as an assistive hand while to a minimal extent and had therefore little use of the
handling and holding household objects (MS) and to SEM Glove (MS, stroke).
carry objects in one hand while walking with assistive “….I have come to realize that the life I live ……there are
devices (MS and stroke) and pursuing bimanual activi- very few activities that I do…”
ties, such as vacuum cleaning, pulling up trousers and
using a wheelbarrow (stroke). Lasting effects on functioning among participants
“Really, I’m not strong enough to hold anything for at who found the SEM Glove useful in ADL
particularly long time… So….but, when I have had the glove, I
have been able to hold a pack of butter and carry it to the table
Lasting effects after using the SEM Glove were repor-
and so on… Good for vacuum-cleaning too, two-hand grip” ted (MS, stroke) and manifested as perceived improved
mobility and strength (MS, stroke) as well as improved
The SEM Glove was found to be assistive in pursuing
grip (MS, stroke) and coordination (stroke). Lingering
leisure activities (MS and stroke) and physical rehabi-
paraesthesia in the hand after use was expressed as a
litation interventions (stroke).
positive result (stroke) as well as decreased spasticity
“Yes, and then, so, if I’m sitting in the garage or the tool
shed, I can hold a thing much better with the left hand now.”
after use in addition to improved mobility and coor-
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dination in the fingers (MS).

For other participants the physical training exercises “It has given me a great deal; it got my hand going again….
were the only activities in which the SEM Glove was as I couldn’t use it before”

Table VI. Clinical characteristics of the participants who did not find the SEM Glove to be useful in ADL (n = 5)
Method of assessment and indicated limitation or
impairment level P11 P12 P13 P14 P15
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Diagnosis Stroke Stroke MS MS MS

Sex Woman Man Woman Woman Woman
Gloved hand, Non-dominant/Dominant Non-d D D Non-d D
Overall disability and dependence, mRS, 1–6 points 4 2 4 4 2
Dependence in mobility and/or personal care, 65 100 70 40 100
Barthel Index < 95 points
Grasp, ARAT max < 18 points 11 12 12 18 16
Grip, ARAT max < 12 points 8 8 8 10 12
Pinch, ARAT max < 18 points 11 14 10 15 15
Gross movement, ARAT< 9 points 6 7 6 7 9
Total score ARAT< 57 points 36 41 36 50 52
Manual dexterity, Box and block test women < 64–66 18 47 27 33 56
blocks, men < 63–68 blocks
Sensory function, Fugl-Meyer upper extremity < 12 points 4 12 11 9 10
Spasticity. Neuroflexor hand flexors NC > 3.4 N 0.05 1.63 3.32 –0.21 0.20
Spasticity, Ashworth internal rotators, biceps, triceps, Yes Yes No No No
supinators and/or pronators > 0
Spasticity, Ashworth hand and/or finger flexors > 0 Yes Yes No No No
Active ROM extension of dig I–V Full Impaired Full Impaired Full
Grip strength, women < 20–22 kg, men < 35–37 kg 8 15 7 6 20
Reported reasons for not finding the glove useful No assistance in Too high a level No assistance Sensor placement. Sensor placement. No
fine hand use of functioning in fine hand use No assistance in assistance in fine hand
releasing the grip use and wrist support.

mRS: Modified Rankin Scale; ARAT: Action Research Arm Test; NC: Neural Component; N: Newton; MAS: Modified Ashworth Scale; ROM: range of motion; dig:
Digitorum; MS: multiple sclerosis; ADL: activities of daily living.
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J Rehabil Med 52, 2020

 p. 8 of 12 S. Palmcrantz et al.

Using the SEM Glove also improved the awareness of it felt as it would have worked well if I had been able to move
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the hand (MS, stroke). my wrist better… because that should also be included.”
“…the grip has improved and, as I said, it’s like my brain In addition, the SEM Glove was found to trigger spas-
has learned that I have a left hand.” ticity, and this made the thumb move in a movement
While others found no lasting effects on hand function trajectory where the sensor of the thumb did not con-
(MS, stroke). nect to the object (MS), while others found it to be
too slow for fast movements, e.g. when playing the
Journal of Rehabilitation Medicine

“It is just as flaccid and indifferent as before”

guitar (stroke).
Level of functioning needed for beneficial effects of Moreover, the motor unit and cord were found to
using the SEM Glove among participants who found be too heavy and clumsy (MS, stroke) and restricted
the glove useful in ADL mobility, e.g. when changing from a standing to sitting
position, going to the toilet or when kept in a bag on
Some participants stated that the SEM Glove should the wheelchair (MS, stroke). The glove, cord and motor
have been introduced earlier when the participant still unit were found to hinder putting on shirts, jackets and
had a higher level of functioning (MS). gloves and the glove could not be fitted under a winter
“The positive side is that the glove helps the grip and on glove or winter clothing (MS, stroke).
the negative side is that I should have had it earlier before
“I had imagined something more modern.. almost an invi-
my ability disappeared.”
sible, small, slim, electronic gadget. So, it feels rather bulky
Other participants found that the SEM Glove would be and the cord is rather thick. The same goes for the computer
more suitable for people with a higher level of functio- that you are supposed to put somewhere.”
ning and impairments related only to endurance (MS, The plastic component in the palm of the hand was
stroke) or grip (MS), and who were able to open their found to hinder the grip when handling objects (MS,
hand fully voluntarily (stroke) or needed assistance stroke) and could negatively affect the motivation to
only for the dominant hand (MS). use the SEM Glove (MS).
“Hold things during a longer period of time but… Yes, but The fabric was found to affect sensory function
I suppose I would recommend someone who thinks that´s their negatively and was yet another reason for experienced
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main problem… For me it’s more like I believe that my arm is

limitation in writing while using the SEM Glove
too weak and I’m too weak outwards, to stretch my fingers.”
(stroke). The fact that the glove could not be used with
Learning period among participants who found the an iPad® was perceived as negative, as the fingertips of
the glove had to be lifted away temporarily (MS). Yet,
SEM Glove useful in ADL
fingers were also found to be supported by the fabric
The participants experienced a learning period, during of the glove when writing on the computer (MS). As
which they learned how to individualize putting on the the participants had been informed that the glove was
Journal of Rehabilitation Medicine

glove, and to get used to the SEM Glove in activities not water-resistant, use in activities involving water,
(MS, stroke). Experiences of finally using the glove such as hand-washing and other self-care activities,
spontaneously were reported, but also that some ac- were found to be a restricting factor (MS, stroke). The
tivities were avoided due to the shortcomings of the fact that users had to wear a plastic glove on top of the
glove (stroke). glove for protection when cooking made it even more
“It’s that thing about increasing the strength and those difficult to use (stroke).
things with the fingertips and so on….and it took a while be-
“It is really hard that you can’t feel the pen.”
fore I learned….for me, anyhow, it was complicated…Before
you got used to the feeling of it, right.” “But, on the negative side is that you can’t use it in water.
If I’m to rinse something in the sink, I must….then it´s only
the right arm I can use and I can’t wash my hands either. “
Activity performance related to the construction of
Donning and doffing was also found to be problematic
the SEM Glove among participants who found the
(MS, stroke). One participant could not put on the SEM
glove useful in ADL Glove without assistance and had to wear the glove
The construction of the SEM Glove was found to sup- between activities, although the participants would
port the wrist, which in turn supported the grip (stroke), have preferred to take it off (MS). The fact that the
while others found that the glove did not support the batteries needed to be replaced and that the glove was
wrist (MS, stroke), which, e.g. limited the ability to write difficult to put on made one participant use the glove
with a pen (stroke) and regretted that additional wrist less and less (MS).
support could not be combined with the glove (MS). “In the beginning it was problematic… because… my fing-
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“…So it was both good and bad. In one way I could hold ers are so stiff, you know…. and then it’s a bit…. you learn to
the pen better because then you use a three-finger grip… so open out all five fingers. It can be problematic.”

www.medicaljournals.se/jrm
 Usability of an assistive soft robotic glove p. 9 of 12

Another aspect experienced by participants in the po- hand was another aspect that negatively affected the
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sitive group was the lack of assistance in opening the participants’ ability and motivation to use the glove
hand in order to initiate the grip and loosen the grip (MS).
voluntarily (MS, stroke). This was reported to be due “As there is a hard device in the palm of my hand I can’t
to the participants’ impaired extension function of the walk with my crutches and I walk with my crutches all the
fingers (MS, stroke). time, you know”
The SEM Glove was not found to be assistive, as the
Journal of Rehabilitation Medicine

“Really my…I’m quite strong in clenching my hand, but

I’m really weak when it comes to opening it.” sensors were not found to touch smaller objects, such
“But I feel that, for my complaints, it would have been as a knife and fork, a plate, the handle of a jug, a cup
better if I had put on the glove upside down… then you can or buttons (MS).
let go.” “If the sensors had touched the cutlery, but they sort of
ended up on the side, or how to put it. You don’t hold the
Body function and activity performance in ADL cutlery that way, really, right on the fingertips like this, but
among participants who did not find the SEM Glove on the side, or how to put it.”
useful in ADL
None of the participants in this group identified ADL DISCUSSION
where the SEM Glove was perceived as being useful This explorative study demonstrates both the poten-
(MS, stroke). A shortcoming of the glove was repor- tial and limitations of the current version of the SEM
ted as being related to its limitations in assisting in Glove when used as an ADL assistive tool by people
handling objects requiring fine hand use including with impaired hand function due to prior stroke or MS.
involvement of the index finger (MS, stroke). The weekly follow-ups and semi-structured interviews
“Well, yes, it´s the fine hand use that’s my problem, but it showed that participants tested the SEM Glove in a
was not of any use”
wide range of activities, indicating that expectations
Again, the SEM Glove, cord and computer were found were high, although not always met. The interview
to be too bulky and heavy and too complicated to results also reflect the complexity of everyday life use
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handle while dressing, moving, and transferring from of the arm and hand where a single activity may involve
a wheelchair, e.g. while using the toilet (MS, stroke). not only grasp but also grip and pinch and complex
Another negative aspect experienced in this group was fine hand use (33). Usability was clearly related to
the lack of assistance with opening the hand in order to activities requiring a strong and prolonged grip, but
initiate the grip and loosen the grip voluntarily (MS). not fine hand use, which might instead be negatively
“If you get assistance with the grip, in itself, that’s good affected by the glove.
but then if you need to get it back, like me, I have difficulties Overall, the results from the interviews showed that
with my left hand to get it to open up, like this.”
Journal of Rehabilitation Medicine

there were more participants who were positive about

Other participants found that although the grip around using the SEM Glove than those who were negative,
an object was tightened with assistance of the SEM and the perceptions of using the glove were shared
Glove, the participant could still not perform the acti- both by participants with stroke and MS. Using a
vity due to proximal weakness of the wrist or arm (MS) mixed methods embedded design, perceived usability
“I can’t say that it was very positive, although there was in terms of a stronger grip was found among a group
a good grab around the glass because then I have difficulty of participants with impaired grasp, grip and pinch,
lifting this arm towards my mouth.”
but who could achieve points around the mid-third of
the ARAT total score and with no or a mild sensory
Lasting effects on functioning among participants impairment and independence in ADL. Participants
who did not find the SEM Glove useful in ADL who did not find the SEM Glove usable comprised
The participants experienced no lasting effects on hand both those with a high level of functioning, where the
function (MS, stroke). SEM Glove potentially hindered activity performance,
“No, the same as usual, the same as usual” such as fine hand use, but also participants, who could
not participate in everyday ADL where the SEM Glove
Activity performance related to the construction of could be useful. Results from the current study could
the SEM Glove among participants who did not find potentially be used as a guide in identifying people
who may find the glove useful in the long-term. Still,
the glove useful in ADL
not all participants fitted these descriptions and dis-
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Again, the SEM Glove, cord and motor unit was found advantages were reported by all. Thus, expectations
to be too bulky and limiting movement and mobility and intended use should be mapped thoroughly before
(MS, stroke). The plastic component in the palm of the recommending the SEM Glove.

J Rehabil Med 52, 2020

 p. 10 of 12 S. Palmcrantz et al.

Based on the results from the weekly telephone for example, impaired attention, executive and memory
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interviews, continued use over the 6 weeks’ interven- functions, which may contribute to a limited activity
tion was found to decline in some participants, who level and participation (35, 38). During rehabilitation,
did not find suitable activities due to overall disability. this complexity of impairments and activity limitations
This agrees with observations from other studies. In a must be considered when goals are set for regaining
study of people living with mild to moderate impair- functioning at a level where the patient can return home
ments in the upper extremity in the long-term phase with an activity level that enables maintained and/or
Journal of Rehabilitation Medicine

after stroke, perceived ability to perform hand ADL further regained functioning.
was associated not only with fine manual dexterity, In the current study, limitations related to the con-
including the ability to coordinate finger movements struction of the SEM Glove were pointed out by the
during grasping, manipulating and releasing the grip, participants in the interviews. These were related to
but also with perceived participation in ADL (34). In placement of the sensors, the fabric and the speed of
a study of participants living with MS and moderate the movements and should be considered in the further
disability (mean Expanded Disability Status Scale development of the glove so as to increase its usability.
(EDSS) 6), fine manual dexterity was also found to Furthermore, the size, weight and placement of the cord
be associated with the ability to participate in ADL and computer were issues reported to limit continuous
in the home setting (35). Together, these findings and use. The reported problems in putting on the glove indi-
previous reports suggest that to increase participation cate that the wearer needs to be able to relax and extend
in daily life activities, an assistive glove must provide their fingers. These requirements are commonly not met
assistance in fine hand use. among persons with CNS disorders, due to increased
The results from the interviews in the current study muscle tone and impaired motor function. Instead self-
indicate that the SEM Glove may increase some wea- sufficiency is limited and an immediate access to as-
rers’ awareness of the hand, and potentially the use of sistance with donning and doffing is needed. This issue
the hand in ADL. Using assistive devices in the home needs to be addressed, as a requirement for continuous
setting may be a way to accomplish an activity level use in ADL is that the wearer can put the glove on and
where the patient is more engaged in ADL, and that take it off without too much time and effort. In a new
JRM

may induce an increase in level of functioning. It is version of the glove, called the Carbonhand (https://
worth noting that, among persons discharged home www.bioservo.com/healthcare), the ease of putting on
with a mean ARAT total score as high as 42 p, the the glove has been considered in the design.
daily activity level of the less-affected hand has been A key limitation of the current version of the SEM
found to be 3 times higher than the affected hand at Glove is the lack of an opening function. In the inter-
12-months post-stroke, despite an increase to 57 p (max views, the need for assistance in opening the hand and
score) in mean (36). One plausible explanation is the fingers was commonly reported by the participants
Journal of Rehabilitation Medicine

so called “learned non-use”, meaning that the person within a wide range of functioning and not only as a
compensates for their limitations in hand activities matter related to putting on the glove, but for a num-
to a degree where they do not use the affected hand, ber of everyday life activities. The ability to actively
e.g. because it is less strenuous and quicker to use the extend the wrist and fingers is commonly impaired
less-affected hand (37). Using an assistive glove could after a CNS lesion with upper extremity paresis (37,
potentially increase the perceived usability of the hand 39). Thus, to meet the needs of a vast population living
in ADL, and thus prevent negative effects, such as with limited hand function due to CNS disorders, as-
“learned non-use”. sistance in opening function is a crucial function in
When using the SEM Glove and in future develop- addition to the closing function of an assistive and/or
ment projects in this area several factors need to be ta- rehabilitative robotic glove.
ken into consideration. Paresis of the hand due to CNS The need for wrist support is another issue that was
disorders is usually manifested by weakness, dysco- clearly expressed in the interviews in this study. The
ordination, disturbed spinal reflexes and muscle tone, ability to actively extend and sustain the extension
as well as impaired sensory function. In case of severe of the wrist is crucial for producing a powerful grasp
paresis, abnormal hand posture due to spastic dystonia and grip and is often seen in impaired hand function
as well as co-contraction of antagonist muscles during due to injury or disease in the CNS (37, 40, 41). The
voluntary activation may be seen, which offer signi- current version of the SEM Glove does not provide
ficant challenges that always need to be considered support to the wrist, and not all participants were able
for these patients. Furthermore, most often not only to use their external wrist support with the SEM Glove.
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the hand is affected but the whole upper extremity is Further development of a glove should preferably
impaired as well as trunk and lower extremity function. include adjustments to enable the use of various wrist
Cognitive functions may also be affected, resulting in, supports currently on the market, and the development

www.medicaljournals.se/jrm
 Usability of an assistive soft robotic glove p. 11 of 12

of a dynamic wrist support is highly recommended in the therapist in the fitting and setting of the SEM Glove, but were
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further development of the SEM glove. not otherwise involved in methods, data collection, analyses or
manuscript writing. Funding was also provided by a donation
The further development of assistive and training by Lars Hedlund (Karolinska Institutet Dnr 2-1582/2016).
devices for persons with impaired hand function will Researchers involved in the study have no conflicts of interest
probably also include other command systems than to declare.
those used in the current version of the SEM Glove.
Electromyography is already used in some exoske-
Journal of Rehabilitation Medicine

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