The Effect of 30-Day Adequate Transitions of Acute Stroke Care on 90-Day Readmission or Death.

OBJECTIVES: We explore patient-reported behaviors and activities within 30-days post-stroke hospitalization and their role in reducing death or readmissions within 90-days post-stroke. METHODS: We constructed the adequate transitions of care (ATOC) composite score, measuring patient-reported participation in eligible behaviors and activities (diet modification, weekly exercise, follow-up medical appointment attendance, medication adherence, therapy use, and toxic habit cessation) within 30 days post-stroke hospital discharge. We analyzed ATOC scores in ischemic and intracerebral hemorrhage stroke patients discharged from the hospital to home or rehabilitation facilities and enrolled in the NIH-funded Transitions of Care Stroke Disparities Study (TCSD-S). We utilized Cox regression analysis, with the progressive adjustment for sociodemographic variables, social determinants of health, and stroke risk factors, to determine the associations between ATOC score within 30-days and death or readmission within 90-days post-stroke. RESULTS: In our sample of 1239 stroke patients (mean age 64+/-14, 58% male, 22% Hispanic, 22% Black, 52% White, 76% discharged home), 13% experienced a readmission or death within 90 days (3 deaths, 160 readmissions, 3 readmissions with subsequent death). Seventy percent of participants accomplished a ≥75% ATOC score. A 25% increase in ATOC was associated with a respective 20% (95% CI 3%-33%) reduced risk of death or readmission within 90-days. CONCLUSION: ATOC represents modifiable behaviors and activities within 30-days post-stroke that are associated with reduced risk of death or readmission within 90-days post-stroke. The ATOC score should be validated in other populations, but it can serve as a tool for improving transitions of stroke care initiatives and interventions.

A Novel, Wearable Inertial Measurement Unit for Stroke Survivors: Validity, Acceptability, and Usability.

OBJECTIVE: To establish the concurrent validity, acceptability, and sensor optimization of a consumer-grade, wearable, multi-sensor system to capture quantity and quality metrics of mobility and upper limb movements in stroke survivors. DESIGN: Single-session, cross-sectional. SETTING: Clinical research laboratory. PARTICIPANTS: Thirty chronic stroke survivors (age 57 (10) years; 33% female) with mild to severe motor impairments participated. INTERVENTIONS: Not Applicable. MAIN OUTCOME MEASURES: Participants donned 5 sensors and performed standardized assessments of mobility and upper limb (UL) movement. True/false, positive/negative time in active movement for the UL were calculated and compared to criterion-standards using an accuracy rate. Bland-Altman plots and linear regression models were used to establish concurrent validity of UL movement counts, step counts, and stance time symmetry of MiGo against established criterion-standard measures. Acceptability and sensor optimization were assessed through an end-user survey and decision matrix. RESULTS: Mobility metrics showed excellent association with criterion-standards for step counts (video: r=0.988, P<.001, IMU: r=0.921, P<.001) and stance-time symmetry (r=0.722, P<.001). In the UL, movement counts showed excellent to good agreement (paretic: r=0.849, P<.001, nonparetic: r=0.672, P<.001). Accuracy of active movement time was 85.2% (paretic) and 88.0% (nonparetic) UL. Most participants (63.3%) had difficulty donning/doffing the sensors. Acceptability was high (4.2/5). CONCLUSIONS: The sensors demonstrated excellent concurrent validity for mobility metrics and UL movements of stroke survivors. Acceptability of the system was high, but alternative wristbands should be considered.

Wearable Technology to Capture Arm Use of People With Stroke in Home and Community Settings: Feasibility and Early Insights on Motor Performance.

OBJECTIVE: The objectives of this study were to establish the short-term feasibility and usability of wrist-worn wearable sensors for capturing the arm and hand activity of people with stroke and to explore the association between factors related to the use of the paretic arm and hand. METHODS: Thirty people with chronic stroke were monitored with wrist-worn wearable sensors for 12 hours per day for a 7-day period. Participants also completed standardized assessments to capture stroke severity, arm motor impairments, self-perceived arm use, and self-efficacy. The usability of the wearable sensors was assessed using the adapted System Usability Scale and an exit interview. Associations between motor performance and capacity (arm and hand impairments and activity limitations) were assessed using Spearman correlations. RESULTS: Minimal technical issues or lack of adherence to the wearing schedule occurred, with 87.6% of days procuring valid data from both sensors. The average sensor wear time was 12.6 (standard deviation [SD] = 0.2) hours per day. Three participants experienced discomfort with 1 of the wristbands, and 3 other participants had unrelated adverse events. There were positive self-reported usability scores (mean = 85.4/100) and high user satisfaction. Significant correlations were observed for measures of motor capacity and self-efficacy with paretic arm use in the home and the community (Spearman correlation coefficients = 0.44-0.71). CONCLUSIONS: This work demonstrates the feasibility and usability of a consumer-grade wearable sensor for capturing paretic arm activity outside the laboratory. It provides early insight into the everyday arm use of people with stroke and related factors, such as motor capacity and self-efficacy. IMPACT: The integration of wearable technologies into clinical practice offers new possibilities to complement in-person clinical assessments and to better understand how each person is moving outside of therapy and throughout the recovery and reintegration phase. Insight gained from monitoring the arm and hand use of people with stroke in the home and community is the first step toward informing future research with an emphasis on causal mechanisms with clinical relevance.

Validity and reliability of inertial measurement units for gait assessment within a post stroke population.

BACKGROUND: The ability to objectively measure spatiotemporal metrics within individuals post-stroke is integral to plan appropriate intervention, track recovery, and ultimately improve efficacy of rehabilitation programs. Inertial measurement units (IMUs) provide a means to systematically collect gait-specific metrics that could not otherwise be obtained from clinical outcomes. However, the use of IMUs to measure spatiotemporal parameters in stroke survivors has yet to be validated. The purpose of this study is to determine the validity and reliability of IMU-recorded spatiotemporal gait metrics as compared to a motion capture camera system (MCCS) in individuals post-stroke. METHODS: Participants (n = 23, M/F = 12/11, mean (SD) age = 50.2(11.1) spatiotemporal data were collected simultaneously from a MCCS and APDM Opal IMUs during a five-minute treadmill walking task at a self-selected speed. Criterion validity and test-retest reliability were assessed using Lin's concordance correlation coefficients (CCCs) and intraclass correlation coefficients (ICCs), respectively. Spatiotemporal values from MCCS and IMU were used to calculate gait asymmetry, and a t-test was used to assess the difference between asymmetry values. RESULTS: There were fair-to-excellent agreement between IMU and MCCS of temporal parameters (CCC 0.56-0.98), excellent agreement of spatial parameters (CCC >0.90), and excellent test-retest reliability for all parameters (ICC >0.90). CONCLUSIONS: Compared to motion capture, the APDM Opal IMUs produced accurate and reliable measures of spatiotemporal parameters. Findings support the use of IMUs to assess spatiotemporal parameters in individual's post-stroke.

Understanding stroke survivors' preferences regarding wearable sensor feedback on functional movement: a mixed-methods study.

BACKGROUND: In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors' preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine the ease of understanding and movement encouragement of feedback based on wearable sensor data (both arm/hand use and mobility) for stroke survivors and to identify preferences for feedback metrics (mode, content, frequency, and timing). METHODS: A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of feedback about arm/hand use, step counts and gait symmetry. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change. RESULTS: Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: (1) Motivation for behavior change, (2) Real-time feedback based on individual goals, and (3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting. CONCLUSION: The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment.

Understanding preferences of stroke survivors for feedback provision about functional movement behavior from wearable sensors: a mixed-methods study.

Background: In stroke rehabilitation, wearable technology can be used as an intervention modality by providing timely, meaningful feedback on motor performance. Stroke survivors' preferences may offer a unique perspective on what metrics are intuitive, actionable, and meaningful to change behavior. However, few studies have identified feedback preferences from stroke survivors. This project aims to determine stroke survivors' satisfaction with feedback from wearable sensors (both mobility and arm/hand use) and to identify preferences for feedback type and delivery schedule. Methods: A sample of 30 chronic stroke survivors wore a multi-sensor system in the natural environment over a 1-week monitoring period. The sensor system captured time in active movement of each arm, arm use ratio, step counts and stance time symmetry. Using the data from the monitoring period, participants were presented with a movement report with visual displays of quantitative and qualitative feedback. A survey and qualitative interview were used to assess ease of understanding, actionability and components of feedback that users found most meaningful to drive lasting behavior change. Results: Arm/hand use and mobility sensor-derived feedback metrics were easy to understand and actionable. The preferred metric to encourage arm/hand use was the hourly arm use bar plot, and similarly the preferred metric to encourage mobility was the hourly steps bar plot, which were each ranked as top choice by 40% of participants. Participants perceived that quantitative (i.e., step counts) and qualitative (i.e., stance time symmetry) mobility metrics provided complementary information. Three main themes emerged from the qualitative analysis: 1) Motivation for behavior change, 2) Real-time feedback based on individual goals, and 3) Value of experienced clinicians for prescription and accountability. Participants stressed the importance of having feedback tailored to their own personalized goals and receiving guidance from clinicians on strategies to progress and increase functional movement behavior in the unsupervised home and community setting. Conclusion: The resulting technology has the potential to integrate engineering and personalized rehabilitation to maximize participation in meaningful life activities outside clinical settings in a less structured environment-one where stroke survivors live their lives.

Wearable technology to capture arm use of stroke survivors in home and community settings: feasibility and early insights on motor performance.

Objective: To establish short-term feasibility and usability of wrist-worn wearable sensors to capture arm/hand activity of stroke survivors and to explore the association between factors related to use of the paretic arm/hand. Methods: 30 chronic stroke survivors were monitored with wrist-worn wearable sensors during 12h/day for a 7-day period. Participants also completed standardized assessments to capture stroke severity, arm motor impairments, self-perceived arm use and self-efficacy. Usability of the wearable sensors was assessed using the adapted System Usability Scale and an exit interview. Associations between motor performance and capacity (arm/hand impairments and activity limitations) were assessed using Spearman's correlations. Results: Minimal technical issues or lack of adherence to the wearing schedule occurred, with 87.6% of days procuring valid data from both sensors. Average sensor wear time was 12.6 (standard deviation: 0.2) h/day. Three participants experienced discomfort with one of the wristbands and three other participants had unrelated adverse events. There were positive self-reported usability scores (mean: 85.4/100) and high user satisfaction. Significant correlations were observed for measures of motor capacity and self-efficacy with paretic arm use in the home and the community (Spearman's correlation ρs: 0.44-0.71). Conclusions: This work demonstrates the feasibility and usability of a consumer-grade wearable sensor to capture paretic arm activity outside the laboratory. It provides early insight into stroke survivors' everyday arm use and related factors such as motor capacity and self-efficacy. Impact: The integration of wearable technologies into clinical practice offers new possibilities to complement in-person clinical assessments and to better understand how each person is moving outside of therapy and throughout the recovery and reintegration phase. Insights gained from monitoring stroke survivors arm/hand use in the home and community is the first step towards informing future research with an emphasis on causal mechanisms with clinical relevance.

Quantifying intra- and interlimb use during unimanual and bimanual tasks in persons with hemiparesis post-stroke.

BACKGROUND: Individuals with hemiparesis post-stroke often have difficulty with tasks requiring upper extremity (UE) intra- and interlimb use, yet methods to quantify both are limited. OBJECTIVE: To develop a quantitative yet sensitive method to identify distinct features of UE intra- and interlimb use during task performance. METHODS: Twenty adults post-stroke and 20 controls wore five inertial sensors (wrists, upper arms, sternum) during 12 seated UE tasks. Three sensor modalities (acceleration, angular rate of change, orientation) were examined for three metrics (peak to peak amplitude, time, and frequency). To allow for comparison between sensor data, the resultant values were combined into one motion parameter, per sensor pair, using a novel algorithm. This motion parameter was compared in a group-by-task analysis of variance as a similarity score (0-1) between key sensor pairs: sternum to wrist, wrist to wrist, and wrist to upper arm. A use ratio (paretic/non-paretic arm) was calculated in persons post-stroke from wrist sensor data for each modality and compared to scores from the Adult Assisting Hand Assessment (Ad-AHA Stroke) and UE Fugl-Meyer (UEFM). RESULTS: A significant group × task interaction in the similarity score was found for all key sensor pairs. Post-hoc tests between task type revealed significant differences in similarity for sensor pairs in 8/9 comparisons for controls and 3/9 comparisons for persons post stroke. The use ratio was significantly predictive of the Ad-AHA Stroke and UEFM scores for each modality. CONCLUSIONS: Our algorithm and sensor data analyses distinguished task type within and between groups and were predictive of clinical scores. Future work will assess reliability and validity of this novel metric to allow development of an easy-to-use app for clinicians.

Ipsilesional arm training in severe stroke to improve functional independence (IPSI): phase II protocol.

BACKGROUND: We previously characterized hemisphere-specific motor control deficits in the ipsilesional, less-impaired arm of unilaterally lesioned stroke survivors. Our preliminary data indicate these deficits are substantial and functionally limiting in patients with severe paresis. METHODS: We have designed an intervention ("IPSI") to remediate the hemisphere-specific deficits in the ipsilesional arm, using a virtual-reality platform, followed by manipulation training with a variety of real objects, designed to facilitate generalization and transfer to functional behaviors encountered in the natural environment. This is a 2-site (primary site - Penn State College of Medicine, secondary site - University of Southern California), two-group randomized intervention with an experimental group, which receives unilateral training of the ipsilesional arm throughout 3 one-hour sessions per week for 5 weeks, through our Virtual Reality and Manipulation Training (VRMT) protocol. Our control group receives a conventional intervention on the contralesional arm, 3 one-hour sessions per week for 5 weeks, guided by recently released practice guidelines for upper limb rehabilitation in adult stroke. The study aims to include a total of 120 stroke survivors (60 per group) whose stroke was in the territory of the middle cerebral artery (MCA) resulting in severe upper-extremity motor impairments. Outcome measures (Primary: Jebsen-Taylor Hand Function Test, Fugl-Meyer Assessment, Abilhand, Barthel Index) are assessed at five evaluation points: Baseline 1, Baseline 2, immediate post-intervention (primary endpoint), and 3-weeks (short-term retention) and 6-months post-intervention (long-term retention). We hypothesize that both groups will improve performance of the targeted arm, but that the ipsilesional arm remediation group will show greater improvements in functional independence. DISCUSSION: The results of this study are expected to inform upper limb evaluation and treatment to consider ipsilesional arm function, as part of a comprehensive physical rehabilitation strategy that includes evaluation and remediation of both arms. TRIAL REGISTRATION: This study is registered with ClinicalTrials.gov (Registration ID: NCT03634397 ; date of registration: 08/16/2018).

mHealth technologies used to capture walking and arm use behavior in adult stroke survivors: a scoping review beyond measurement properties.

PURPOSE: We aimed to provide a critical review of measurement properties of mHealth technologies used for stroke survivors to measure the amount and intensity of functional skills, and to identify facilitators and barriers toward adoption in research and clinical practice. MATERIALS AND METHODS: Using Arksey and O'Malley's framework, two independent reviewers determined eligibility and performed data extraction. We conducted an online consultation survey exercise with 37 experts. RESULTS: Sixty-four out of 1380 studies were included. A majority reported on lower limb behavior (n = 32), primarily step count (n = 21). Seventeen studies reported on arm-hand behaviors. Twenty-two studies reported metrics of intensity, 10 reported on energy expenditure. Reliability and validity were the most frequently reported properties, both for commercial and non-commercial devices. Facilitators and barriers included: resource costs, technical aspects, perceived usability, and ecological legitimacy. Two additional categories emerged from the survey: safety and knowledge, attitude, and clinical skill. CONCLUSIONS: This provides an initial foundation for a field experiencing rapid growth, new opportunities and the promise that mHealth technologies affords for envisioning a better future for stroke survivors. We synthesized findings into a set of recommendations for clinicians and clinician-scientists about how best to choose mHealth technologies for one's individual objective.Implications for RehabilitationRehabilitation professionals are encouraged to consider the measurement properties of those technologies that are used to monitor functional locomotor and object-interaction skills in the stroke survivors they serve.Multi-modal knowledge translation strategies (research synthesis, educational courses or videos, mentorship from experts, etc.) are available to rehabilitation professionals to improve knowledge, attitude, and skills pertaining to mHealth technologies.Consider the selection of commercially available devices that are proven to be valid, reliable, accurate, and responsive to the targeted clinical population.Consider usability and privacy, confidentiality and safety when choosing a specific device or smartphone application.

Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial.

BACKGROUND: Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period. OBJECTIVE: To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT). METHODS: A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day. RESULTS: There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC. CONCLUSIONS: Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.

User-Driven Functional Movement Training With a Wearable Hand Robot After Stroke.

We studied the performance of a robotic orthosis designed to assist the paretic hand after stroke. It is wearable and fully user-controlled, serving two possible roles: as a therapeutic tool that facilitates device-mediated hand exercises to recover neuromuscular function or as an assistive device for use in everyday activities to aid functional use of the hand. We present the clinical outcomes of a pilot study designed as a feasibility test for these hypotheses. 11 chronic stroke (>2 years) patients with moderate muscle tone (Modified Ashworth Scale ≤ 2 in upper extremity) engaged in a month-long training protocol using the orthosis. Individuals were evaluated using standardized outcome measures, both with and without orthosis assistance. Fugl-Meyer post intervention scores without robotic assistance showed improvement focused specifically at the distal joints of the upper limb, suggesting the use of the orthosis as a rehabilitative device for the hand. Action Research Arm Test scores post intervention with robotic assistance showed that the device may serve an assistive role in grasping tasks. These results highlight the potential for wearable and user-driven robotic hand orthoses to extend the use and training of the affected upper limb after stroke.

Gait Adaptation Using a Cable-Driven Active Leg Exoskeleton (C-ALEX) With Post-Stroke Participants.

Individuals with chronic hemiparesis post-stroke exhibit gait impairments that require functional rehabilitation through training. Exoskeletal robotic assistive devices can provide a user with continuous assistance but impose movement restrictions. There are currently devices that allow unrestricted movement but provide assistance only intermittently at specific points of the gait cycle. Our design, a cable-driven active leg exoskeleton (C-ALEX), allows the user both unrestricted movement and continuous force assistance throughout the gait cycle to assist the user in new walking patterns. In this study, we assessed the ability of C-ALEX to induce a change in the walking patterns of ten post-stroke participants using a single-session training protocol. The ability of C-ALEX to accurately provide forces and torques in the desired directions was also evaluated to compare its design performance to traditional rigid-link designs. Participants were able to reach 91% ± 12% of their target step length and 89% ± 13% of their target step height. The achieved step parameters differed significantly from participant baselines ( ). To quantify the performance, the forces in each cable's out of the plane movements were evaluated relative to the in-plane desired cable tension magnitudes. This corresponded to an error of under 2Nm in the desired controlled joint torques. This error magnitude is low compared to the system command torques and typical adult biological torques during walking (2-4%). These results point to the utility of using non-restrictive cable-driven architectures in gait retraining, in which future focus can be on rehabilitating gait pathologies seen in stroke survivors.

Treadmill-Based Locomotor Training With Robotic Pelvic Assist and Visual Feedback: A Feasibility Study.

BACKGROUND AND PURPOSE: Gait asymmetries are common after stroke, and often persist despite conventional rehabilitation. Robots provide training at a greater practice frequency than conventional approaches. However, prior studies of have found the transfer of learned skills outside of the device to be inadequate. The tethered pelvic assist device (TPAD) promotes weight shifting, yet allows users to independently navigate spatiotemporal aspects of gait. The purpose of this study was to evaluate feasibility and preliminary efficacy of a 5-day intervention combining TPAD training with visual feedback and task-specific overground training to promote improved force and stance symmetry in individuals after stroke. METHODS: After baseline assessments, 11 participants chronically after stroke received 1 hour of practice for 5 consecutive days. Training sessions included visual feedback during TPAD treadmill training followed by overground gait training. Safety, perceived exertion, and adherence were recorded as measures of feasibility. Load and stance symmetry were reassessed after the intervention (posttraining) and again 1 week later. RESULTS: No adverse events were reported. Mean (SD) perceived exertion (3.61 (0.23)) was low and did not significantly change throughout the intervention. Overall adherence was 96.4%. Load asymmetry was not significantly reduced on the treadmill from baseline to posttraining (P = 0.075). Overground stance symmetry significantly improved on posttraining (F = 8.498, P = 0.002), but was not sustained at follow-up. (See the Video, Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A311, which summarizes the study background, methods, and results.) DISCUSSION AND CONCLUSIONS:: Results demonstrate this combined interventional approach was feasible and improved stance symmetry overground, yet further work should consider increasing training intensity and/or duration to induce gains lasting through follow-up.

Development of Sensor-Based Measures of Upper Extremity Interlimb Coordination.

The development of motor impairment after the onset of an injury such as stroke may result in long-term compensatory behaviors. Because compensation often evolves in ambient settings (outside the purview of monitoring clinicians), there is a need for quantitative tools capable of accurately detecting the subtleties of compensation and related reduction in interlimb coordination. Improvement in interlimb coordination may serve as a marker of recovery from stroke, and rehabilitation progress. The current study investigates measures of upper extremity interlimb coordination in persons post-stroke and healthy controls. It introduces a novel algorithm for objective characterization of interlimb coordination during the performance of real-world tasks.

EMG pattern classification to control a hand orthosis for functional grasp assistance after stroke.

Wearable orthoses can function both as assistive devices, which allow the user to live independently, and as rehabilitation devices, which allow the user to regain use of an impaired limb. To be fully wearable, such devices must have intuitive controls, and to improve quality of life, the device should enable the user to perform Activities of Daily Living. In this context, we explore the feasibility of using electromyography (EMG) signals to control a wearable exotendon device to enable pick and place tasks. We use an easy to don, commodity forearm EMG band with 8 sensors to create an EMG pattern classification control for an exotendon device. With this control, we are able to detect a user's intent to open, and can thus enable extension and pick and place tasks. In experiments with stroke survivors, we explore the accuracy of this control in both non-functional and functional tasks. Our results support the feasibility of developing wearable devices with intuitive controls which provide a functional context for rehabilitation.

Exploration of Two Training Paradigms Using Forced Induced Weight Shifting With the Tethered Pelvic Assist Device to Reduce Asymmetry in Individuals After Stroke: Case Reports.

Many robotic devices in rehabilitation incorporate an assist-as-needed haptic guidance paradigm to promote training. This error reduction model, while beneficial for skill acquisition, could be detrimental for long-term retention. Error augmentation (EA) models have been explored as alternatives. A robotic Tethered Pelvic Assist Device has been developed to study force application to the pelvis on gait and was used here to induce weight shift onto the paretic (error reduction) or nonparetic (error augmentation) limb during treadmill training. The purpose of these case reports is to examine effects of training with these two paradigms to reduce load force asymmetry during gait in two individuals after stroke (>6 mos). Participants presented with baseline gait asymmetry, although independent community ambulators. Participants underwent 1-hr trainings for 3 days using either the error reduction or error augmentation model. Outcomes included the Borg rating of perceived exertion scale for treatment tolerance and measures of force and stance symmetry. Both participants tolerated training. Force symmetry (measured on treadmill) improved from pretraining to posttraining (36.58% and 14.64% gains), however, with limited transfer to overground gait measures (stance symmetry gains of 9.74% and 16.21%). Training with the Tethered Pelvic Assist Device device proved feasible to improve force symmetry on the treadmill irrespective of training model. Future work should consider methods to increase transfer to overground gait.

Hand Robotic Therapy in Children with Hemiparesis: A Pilot Study.

OBJECTIVE: The aim of this study was to understand the impact of training with a hand robotic device on hand paresis and function in a population of children with hemiparesis. METHODS: Twelve children with hemiparesis (mean age, 9 [SD, 3.64] years) completed participation in this prospective, experimental, pilot study. Participants underwent clinical assessments at baseline and again 6 weeks later with instructions to not initiate new therapies. After these assessments, participants received 6 weeks of training with a hand robotic device, consisting of 1-hour sessions, 3 times weekly. Assessments were repeated on completion of training. RESULTS: Results showed significant improvements after training on the Assisting Hand Assessment (mean difference, 2.0 Assisting Hand Assessment units; P = 0.011) and on the upper-extremity component of the Fugl-Meyer scale (raw score mean difference, 4.334; P = 0.001). No significant improvements between pretest and posttest were noted on the Jebsen-Taylor Test of Hand Function, the Quality of Upper Extremity Skills Test, or the Pediatric Evaluation of Disability Inventory after intervention. Total active mobility of digits and grip strength also failed to demonstrate significant changes after training. INTERPRETATION: Participants tolerated training with the hand robotic device, and significant improvements in bimanual hand use, as well as impairment-based scales, were noted. Improvements were carried over into bimanual skills during play. TO CLAIM CME CREDITS: Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME CME OBJECTIVES: Upon completion of this article, the reader should be able to: (1) Understand key components of neuroplasticity; (2) Discuss the benefits of robotic therapy in the recovery of hand function in pediatric patients with hemiplegia; and (3) Appropriately incorporate robotic therapy into the treatment plan of pediatric patients with hemiplegia. LEVEL: Advanced ACCREDITATION: The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Gait training with a robotic leg brace after stroke: a randomized controlled pilot study.

OBJECTIVE: Robot-aided exercise therapy is a promising approach to enhance walking ability in stroke survivors. This study was designed to test a new robotic knee brace for restoring mobility in stroke survivors. DESIGN: Twenty-four ambulatory individuals with chronic hemiparesis after stroke were enrolled in this pilot study. The participants were randomly assigned in equal numbers to either treatment with the experimental device or to a group exercise program and received a total of 18 hrs of their assigned therapy during a 6-wk training period. The primary outcome was gait velocity, as measured with the 10-m walk test. Secondary measures included 6-min walk test, Timed Up and Go test, Five-Times-Sit-to-Stand test, Romberg test, Emory Functional Ambulation Profile, Berg Balance scale, and the California Functional Evaluation 40. RESULTS: Twenty subjects completed the entire protocol and all follow-up visits. No significant differences between the two groups were found for the primary outcome measure at either the completion of training (week 6) or at the 3-mo follow-up (week 19), with inconsistent findings for secondary measures. No within-group changes were seen in the primary outcome measure (10-m walk test) in either group. Within-group improvements were seen in several of the secondary measures for both groups. No complications of robotic therapy were observed. CONCLUSIONS: Robotic therapy for ambulatory stroke patients with chronic hemiparesis using a robotic knee brace resulted in only modest functional benefits that were comparable with a group exercise intervention.