The findings as a whole indicate that these patients, family caregivers and health professionals with an interest in this area were all hopeful about the potential of assistive technologies to facilitate self-management and improve upper-limb recovery in stroke. The need to increase intensity and repetition of upper limb exercise by facilitating independent practice was recognised by all. Assistive technologies were seen as a potential solution to this.
Before focusing on the implications of these findings, it is important to consider the framework of this research. This research was conducted with people who had expressed an interest in the use of upper-limb assistive technologies in stroke-rehabilitation by attending an exhibition of assistive technology devices. They should, therefore, not be considered representative of the whole population affected by and working with stroke. By attending the exhibition and the focus groups our participants are likely to have more knowledge of and be more positive about the potential of assistive technologies than the population as a whole. We did, however, seek to include the views of a range of stakeholders that included people with stroke and family care-givers with variations in gender and age, who had experience of assistive technologies as well as those who were naïve prior to the exhibition. Health professionals were from the state and private sectors and had a range of assistive technology experience. The strength of this purposively selected group is that they were able to give a depth of views from a range of perspectives. It would be useful to carry out a wider survey of the issues to explore the issues identified further and this is underway.
There are two main issues raised by our findings, each of which will be discussed in turn: i) the urgent need for evidence from clinical settings to support assistive technology use in stroke upper-limb rehabilitation and ii) other potential barriers to the use of assistive technologies in the self-management of stroke.
From the patients’ and family caregivers’ perspective, little therapy is currently being provided for their arms or hands; assistive technologies offer the hope of improvement, but they are unable to access unbiased professional advice and risk buying products that may not meet their needs. The extent of the effectiveness of different assistive technologies has not been established in clinical settings. Therapists are reluctant to provide advice on assistive technologies, have difficulty assessing the impact of assistive technologies on their practice, and cannot gain funding for assistive technologies for their patients.
The prevalence of people living with stroke related disability is likely to increase as the population ages. Gathering evidence for therapies which can be both intense and used without therapist supervision, e.g. assistive technologies would be a useful research priority for governments and research funders. Assistive technology use is often underpinned by sound theoretical and evidence based principles at ‘experimental’ level. However translational work to everyday practice is needed which can take into account the heterogeneous nature of the stroke population, exploring the possible differences in benefits for different groups (i.e. large/small infarcts, presence/absence of somatosensory deficit, cognitive impairment etc.).
As well as the issue of research evidence, our findings highlighted several issues associated with self-management practice. The HPCs in this study felt that that many people struggled to become active managers of their own rehabilitation. However, the patients and family caregivers described how they actively sought solutions to their on-going upper-limb disability including searching for information on the internet, contacting companies, and purchasing their own assistive technologies. Kielmann et al. , similarly identified people with respiratory illnesses who saw themselves as active self-carers but who, like the participants in our study, complained of obstacles within the health system which acted as barriers to their self-management and who felt abandoned by the health service. Kennedy et al.,  suggest that self-management cannot focus only on educating patients how to self-care and passing all responsibility for self-management to them. They suggest that self-management requires a whole systems approach which trains health professionals how to work in partnership with patients, and which encourages self-referral to services when patients need advice. Such a partnership approach would be vital to more routine use of assistive technologies in clinical practice.
Ensuring individuals can make informed choices and are supported to use technology are considered key to promoting self-management . In contrast, the patients and families in this study were frustrated that they were not provided with information on assistive technologies by experts who they could trust, realising that a lack of expert advice increased the chance of them wasting their money or purchasing a device which might do harm. Lack of appropriate information is a recurring theme in audits of stroke services [14, 25]. Despite their frustrations, the patients and families did not attribute the problem to individual therapists, who they viewed as overwhelmed and over worked; a barrier that professionals have recognised to their engagement with self-management working . Research suggests that many health professionals have received little formal training to develop self-management skills . Stroke specific training in self-management for staff working in stroke rehabilitation has recently become available  but is still undergoing development and evaluation.
A further concern, expressed by all stakeholders in this study, was the usability of the devices; an issue which has previously been reported as a barrier to self-management by health professionals . Our findings identified design issues with the devices themselves which, if resolved, may encourage the adoption of assistive technologies into upper-limb rehabilitation. The use of an iterative design process, which embeds stakeholder feedback throughout the design cycle, is advocated . Simply improving the devices is not, however, likely to be enough. Other psychosocial and organisational factors including communication channels, time, and the social system will also impact on device uptake . Moving from adoption to the imbedding of technologies into routine practice is also problematic. Normalisation Process Theory  offers propositions to explain some of the integration issues identified in this research. For instance, the problem of ‘raising false hopes’ may hamper the integration of assistive technologies into practice because of the interactional challenge generated between professionals and patients; whilst the systemic problems relate to issues about the allocation and control of resources and how assistive technology provision can be integrated into existing patterns of activity. Both of these factors pose challenges to the normalisation of assistive technologies in rehabilitation practice that will need to be addressed if they are to serve as useful tools for self-management.