A Convergent Mixed Methods Design to Assess the Use of the Home Virtual Rehabilitation System By Persons with Chronic Stroke.

Purpose: Patients poststroke utilized the Home Virtual Rehabilitation System (HoVRS) to perform home-based, gamified upper extremity rehabilitation over 12 weeks. Outcomes related to adherence and clinical improvement were collected, and semistructured interviews were conducted to assess intrinsic and extrinsic motivators that impacted engagement with the system. Methods: Subjects performed between 299 and 2020 minutes of self-scheduled, sparsely supervised hand rehabilitation activities in their homes. Results: As a group, the subjects demonstrated statistically significant improvements at the structure/function, activity, and activities of daily living levels of function. Qualitative analysis generated seven themes that both positively and negatively influenced each subject's experience with HoVRS, including challenge as a primary intrinsic motivator and pursuing additional therapy and/or a return to higher functional status as a key extrinsic motivator. Subjects' ratings of the system using the Intrinsic Motivation Inventory before and after treatment were uniformly positive, but interview-based feedback was more balanced between positive and negative.

EEG Based Resting State Connectivity Changes in the Motor Cortex Associated with Upper Limb Motor Recovery in the Subacute Period Post-Stroke.

Stroke is a heterogeneous condition that would benefit from valid biomarkers of recovery for research and in the clinic. We evaluated the change in resting state connectivity (RSC) via electroencephalography (EEG) in motor areas, as well as motor recovery of the affected upper limb, in the subacute phase post-stroke. Fifteen participants who had sustained a subcortical stroke were included in this study. The group made significant gains in upper limb impairment as measured by the Upper Extremity Fugl-Meyer Assessment (UEFMA) from baseline to four months post-stroke (24.78 (SD 5.4)). During this time, there was a significant increase in RSC in the beta band from contralesional M1 to ipsilesional M1. We propose that this change in RSC may have contributed to the motor recovery seen in this group. Clinical Relevance- This study evaluates resting state connectivity measured via EEG as a neural biomarker of recovery post-stroke. Biomarkers can help clinicians understand the potential for recovery after stroke and thus help them to establish therapy goals and determine treatment plans.

Evaluation of Changes in Kinematic Measures of Three Dimensional Reach to Grasp Movements in the Early Subacute Period of Recovery from Stroke.

This study examines longitudinal data of subjects initially examined in the early subacute period of recovery following a stroke with a test of reach to grasp (RTG) kinematics in an attempt to identify changes in movement patterns during the period of heightened neural recovery following a stroke. Subjects (n=8) were a convenience sample of persons with stroke that participated in an intervention trial. Baseline Upper Extremity Fugl Meyer Assessment (UEFMA) scores ranged between 31 and 52 and ages were between 49 and 83. The UEFMA and RTG test were collected prior to intervention, immediately after the intervention (approximately 18 days later post baseline) and one month after the intervention. RTG data for the uninvolved UE was collected at the one-month session. Subjects reached for objects placed on a table 10 cm from their sternums, picking them up and placing them on a target 30 cm from their acromioclavicular joints. Data was collected using an optical motion capture system. Active makers were placed on each fingertip, metacarpophalangeal, and proximal interphalangeal joint. Four additional passive markers were placed on the dorsum of the hand, the elbow, the shoulder, and the sternum. Subjects demonstrated statistically significant improvements in reaching duration, reaching trajectory smoothness, time after peak velocity and peak grip aperture. All of these measures correlated significantly with improvements in UEFMA. Clinical Relevance- Kinematic measures of reaching and grasping collected early in the subacute period of recovery from stroke may offer insight into specific aspects of the recovery of upper extremity motor function that differ from the information gleaned from clinical scales.

Hand Focused Upper Extremity Rehabilitation in the Subacute Phase Post-stroke Using Interactive Virtual Environments.

Introduction: Innovative motor therapies have attempted to reduce upper extremity impairment after stroke but have not made substantial improvement as over 50% of people post-stroke continue to have sensorimotor deficits affecting their self-care and participation in daily activities. Intervention studies have focused on the role of increased dosing, however recent studies have indicated that timing of rehabilitation interventions may be as important as dosing and importantly, that dosing and timing interact in mediating effectiveness. This study is designed to empirically test dosing and timing. Methods and Analysis: In this single-blinded, interventional study, subjects will be stratified on two dimensions, impairment level (Fugl-Meyer Upper Extremity Assessment (FM) and presence or absence of Motor Evoked Potentials (MEPs) as follows; (1) Severe, FM score 10-19, MEP+, (2) Severe, FM score 10-19, MEP-, (3) Moderate, FM score 20-49, MEP+, (4) Moderate, FM score 20-49, MEP-. Subjects not eligible for TMS will be assigned to either group 2 (if severe) or group 3 (if moderate). Stratified block randomization will then be used to achieve a balanced assignment. Early Robotic/VR Therapy (EVR) experimental group will receive in-patient usual care therapy plus an extra 10 h of intensive upper extremity therapy focusing on the hand using robotically facilitated rehabilitation interventions presented in virtual environments and initiated 5-30 days post-stroke. Delayed Robotic/VR Therapy (DVR) experimental group will receive the same intervention but initiated 30-60 days post-stroke. Dose-matched usual care group (DMUC) will receive an extra 10 h of usual care initiated 5-30 days post-stroke. Usual Care Group (UC) will receive the usual amount of physical/occupational therapy. Outcomes: There are clinical, neurophysiological, and kinematic/kinetic measures, plus measures of daily arm use and quality of life. Primary outcome is the Action Research Arm Test (ARAT) measured at 4 months post-stroke. Discussion: Outcome measures will be assessed to determine whether there is an early time period in which rehabilitation will be most effective, and whether there is a difference in the recapture of premorbid patterns of movement vs. the development of an efficient, but compensatory movement strategy. Ethical Considerations: The IRBs of New Jersey Institute of Technology, Rutgers University, Northeastern University, and Kessler Foundation reviewed and approved all study protocols. Study was registered in https://ClinicalTrials.gov (NCT03569059) prior to recruitment. Dissemination will include submission to peer-reviewed journals and professional presentations.

Development of the Home based Virtual Rehabilitation System (HoVRS) to remotely deliver an intense and customized upper extremity training.

BACKGROUND: After stroke, sustained hand rehabilitation training is required for continuous improvement and maintenance of distal function. METHODS: In this paper, we present a system designed and implemented in our lab: the Home based Virtual Rehabilitation System (HoVRS). Fifteen subjects with chronic stroke were recruited to test the feasibility of the system as well as to refine the design and training protocol to prepare for a future efficacy study. HoVRS was placed in subjects' homes, and subjects were asked to use the system at least 15 min every weekday for 3 months (12 weeks) with limited technical support and remote clinical monitoring. RESULTS: All subjects completed the study without any adverse events. Subjects on average spent 13.5 h using the system. Clinical and kinematic data were collected pre and post study in the subject's home. Subjects demonstrated a mean increase of 5.2 (SEM = 0.69) on the Upper Extremity Fugl-Meyer Assessment (UEFMA). They also demonstrated improvements in six measurements of hand kinematics. In addition, a combination of these kinematic measures was able to predict a substantial portion of the variability in the subjects' UEFMA score. CONCLUSION: Persons with chronic stroke were able to use the system safely and productively with minimal supervision resulting in measurable improvements in upper extremity function.

Autonomous Use of the Home Virtual Rehabilitation System: A Feasibility and Pilot Study.

Objective: This article describes the findings of a study examining the ability of persons with strokes to use home virtual rehabilitation system (HoVRS), a home-based rehabilitation system, and the impact of motivational enhancement techniques on subjects' motivation, adherence, and motor function improvements subsequent to a 3-month training program. Materials and Methods: HoVRS integrates a Leap Motion controller, a passive arm support, and a suite of custom-designed hand rehabilitation simulations. For this study, we developed a library of three simulations, which include activities such as flexing and extending fingers to move a car, flying a plane with wrist movement, and controlling an avatar running in a maze using reaching movements. Two groups of subjects, the enhanced motivation (EM) group and the unenhanced control (UC) group, used the system for 12 weeks in their homes. The EM group trained using three simulations that provided 8-12 levels of difficulty and complexity. Graphics and scoring opportunities increased at each new level. The UC group performed the same simulations, but difficulty was increased utilizing an algorithm that increased difficulty incrementally, making adjustments imperceptible. Results: Adherence to both the EM and UC protocols exceeded adherence to home exercise programs described in the stroke rehabilitation literature. Both groups demonstrated improvements in upper extremity function. Intrinsic motivation levels were better for the EM group and motivation levels were maintained for the 12-week protocol. Conclusion: A 12-week home-based training program using HoVRS was feasible. Motivational enhancement may have a positive impact on motivation, adherence, and motor outcome.

The Effect of Movement Phase on the Contralaterally Coordinated Paired Associative Stimulation-Induced Excitability.

Paired associative stimulation (PAS) has been shown to increase corticospinal excitability (CSE) providing a promising adjuvant therapeutic approach for stroke. Combining PAS with movement of the stimulated limb may further increase enhancement of CSE, however, individuals with moderate to severe stroke may not be able to engage in the necessary repetitive voluntary movements of the paretic limb. The objective of this study was to investigate the feasibility of contralaterally coordinated PAS (ccPAS) applied to the resting hand extensors during fast extension of the contralateral hand. A potential dependency of CSE modulation on the phase of the movement of the opposite hand was evaluated. Eleven participants each completed three session: PAS applied to the resting right hand during the preparation phase of the extension of the contralateral (left) hand; PAS applied during the execution phase of the left hand extension; and PAS applied with both hands at rest. Motor evoked potentials (MEPs) were evoked from the right extensor digitorum communis (EDC) and flexor digitorum superficialis (FDS) muscles prior and immediately after each session. PAS delivered during the muscle contraction of the left hand and PAS delivered at rest both increased the MEP amplitude in the right EDC. PAS delivered before the left hand movement onset led to a decrease in the MEP amplitude measured in the right EDC muscle. We conclude that PAS induced bidirectional changes in the amplitude of MEPs that were dependent on the phase of the movement of the opposite hand.

Motor skill changes and neurophysiologic adaptation to recovery-oriented virtual rehabilitation of hand function in a person with subacute stroke: a case study.

PURPOSE: The complexity of upper extremity (UE) behavior requires recovery of near normal neuromuscular function to minimize residual disability following a stroke. This requirement places a premium on spontaneous recovery and neuroplastic adaptation to rehabilitation by the lesioned hemisphere. Motor skill learning is frequently cited as a requirement for neuroplasticity. Studies examining the links between training, motor learning, neuroplasticity, and improvements in hand motor function are indicated. METHODS: This case study describes a patient with slow recovering hand and finger movement (Total Upper Extremity Fugl-Meyer examination score = 25/66, Wrist and Hand items = 2/24 on poststroke day 37) following a stroke. The patient received an intensive eight-session intervention utilizing simulated activities that focused on the recovery of finger extension, finger individuation, and pinch-grasp force modulation. RESULTS: Over the eight sessions, the patient demonstrated improvements on untrained transfer tasks, which suggest that motor learning had occurred, as well a dramatic increase in hand function and corresponding expansion of the cortical motor map area representing several key muscles of the paretic hand. Recovery of hand function and motor map expansion continued after discharge through the three-month retention testing. CONCLUSION: This case study describes a neuroplasticity based intervention for UE hemiparesis and a model for examining the relationship between training, motor skill acquisition, neuroplasticity, and motor function changes. Implications for rehabilitation Intensive hand and finger rehabilitation activities can be added to an in-patient rehabilitation program for persons with subacute stroke. Targeted training of the thumb may have an impact on activity level function in persons with upper extremity hemiparesis. Untrained transfer tasks can be utilized to confirm that training tasks have elicited motor learning. Changes in cortical motor maps can be used to document changes in brain function which can be used to evaluate changes in motor behavior persons with subacute stroke.

Does training with traditionally presented and virtually simulated tasks elicit differing changes in object interaction kinematics in persons with upper extremity hemiparesis?

OBJECTIVE: To contrast changes in clinical and kinematic measures of upper extremity movement in response to virtually simulated and traditionally presented rehabilitation interventions in persons with upper extremity hemiparesis due to chronic stroke. DESIGN: Non-randomized controlled trial. SETTING: Ambulatory research facility. PARTICIPANTS: Subjects were a volunteer sample of twenty one community-dwelling adults (mean age: 51 ± 12 years) with residual hemiparesis due to stroke more than 6 months before enrollment (mean: 74 ± 48 months), recruited at support groups. Partial range, against gravity shoulder movement and at least 10° of active finger extension were required for inclusion. All subjects completed the study without adverse events. INTERVENTIONS: A 2 weeks, 24-hour program of robotic/virtually simulated, arm and finger rehabilitation activities was compared to the same dose of traditionally presented arm and finger activities. RESULTS: Subjects in both groups demonstrated statistically significant improvements in the ability to interact with real-world objects as measured by the Wolf Motor Function Test (P = 0.01). The robotic/virtually simulated activity (VR) group but not the traditional, repetitive task practice (RTP) group demonstrated significant improvements in peak reaching velocity (P = 0.03) and finger extension excursion (P = 0.03). Both groups also demonstrated similar improvements in kinematic measures of reaching and grasping performance such as increased shoulder and elbow excursion along with decreased trunk excursion. CONCLUSIONS: Kinematic measurements identified differing adaptations to training that clinical measurements did not. These adaptations were targeted in the design of four of the six simulations performed by the simulated activity group. Finer grained measures may be necessary to accurately depict the relative benefits of dose matched motor interventions.

Comparing integrated training of the hand and arm with isolated training of the same effectors in persons with stroke using haptically rendered virtual environments, a randomized clinical trial.

BACKGROUND: Robotically facilitated therapeutic activities, performed in virtual environments have emerged as one approach to upper extremity rehabilitation after stroke. Body function level improvements have been demonstrated for robotically facilitated training of the arm. A smaller group of studies have demonstrated modest activity level improvements by training the hand or by integrated training of the hand and arm. The purpose of this study was to compare a training program of complex hand and finger tasks without arm movement paired with a separate set of reaching activities performed without hand movement, to training the entire upper extremity simultaneously, utilizing integrated activities. METHODS: Forty individuals with chronic stroke recruited in the community, participated in a randomized, blinded, controlled trial of two interventions. Subjects were required to have residual hand function for inclusion. The first, hand and arm separate (HAS) training (n=21), included activities controlled by finger movement only, and activities controlled by arm movement only, the second, hand and arm together (HAT) training (n=20) used simulations controlled by a simultaneous use of arm and fingers. RESULTS: No adverse reactions occurred. The entire sample demonstrated mean improvements in Wolf Motor Function Test scores (21%) and Jebsen Test of Hand Function scores (15%), with large effect sizes (partial r2=.81 and r2=.67, respectively). There were no differences in improvement between HAS and HAT training immediately after the study. Subjects in the HAT group retained Wolf Motor Function Test gains better than in the HAS group measured three months after the therapy but the size of this interaction effect was small (partial r2=.17). CONCLUSIONS: Short term changes in upper extremity motor function were comparable when training the upper extremity with integrated activities or a balanced program of isolated activities. Further study of the retention period is indicated. TRIAL REGISTRATION: NCT01072461.

Correlation of reaching and grasping kinematics and clinical measures of upper extremity function in persons with stroke related hemiplegia.

Timed measures of standardized functional tasks are commonly used to measure treatment effects in persons with upper extremity (UE) paresis due to stroke. The effectiveness of their ability to measure motor recovery has come into question because of their inability to distinguish between motor recovery and compensations. This paper presents three linear regression models generated from twelve kinematic measures collected during the performance of a two phase reach/grasp and transport /release activity as performed by 21 persons with upper extremity hemiparesis due to chronic stroke. One of these models demonstrated a statistically significant correlation with the subjects' scores on the Wolf Motor Function Test (WMFT), a battery of fifteen standardized upper extremity functional activities. The second and third models demonstrated a statistically significant correlation with the subjects' WMFT change scores elicited by a two week intensive upper extremity motor rehabilitation intervention. The high correlation suggests that models of kinematic measurements can be used to predict neurologic improvement and the effectiveness of treatment.

Robotic/virtual reality intervention program individualized to meet the specific sensorimotor impairments of an individual patient: a case study.

A majority of studies examining repetitive task practice facilitated by robots for the treatment of upper extremity paresis utilize standardized protocols applied to large groups. This study will describe a virtually simulated, robot-based intervention customized to match the goals and clinical presentation of a gentleman with upper extremity hemiparesis secondary to stroke. MP, the subject of this case, is an 85-year-old man with left hemiparesis secondary to an intracerebral hemorrhage 5 years prior to examination. Outcomes were measured before and after a 1-month period of home therapy and after a 1-month virtually simulated, robotic intervention. The intervention was designed to address specific impairments identified during his PT examination. When necessary, activities were modified based on MP's response to his first week of treatment. MP's home training program produced a 3-s decline in Wolf Motor Function Test (WMFT) time and a 5-s improvement in Jebsen Test of Hand Function (JTHF) time. He demonstrated an additional 35-s improvement in JTHF and an additional 44-s improvement in WMFT subsequent to the robotic training intervention. A 24-h activity measurement and the Hand and Activities of Daily Living scales of the Stroke Impact Scale improved following the robotic intervention. Based on his responses to training we feel that we have established that a customized program of virtually simulated, robotically facilitated rehabilitation was feasible and resulted in larger improvements than an intensive home training program in several measurements of upper extremity function in our patient with chronic hemiparesis.

Virtual Reality for Sensorimotor Rehabilitation Post-Stroke: The Promise and Current State of the Field.

Developments over the past 2 years in virtual reality (VR) augmented sensorimotor rehabilitation of upper limb use and gait post-stroke were reviewed. Studies were included if they evaluated comparative efficacy between VR and standard of care, and or differences in VR delivery methods; and were CEBM (center for evidence based medicine) level 2 or higher. Eight upper limb and two gait studies were included and described using the following categories hardware (input and output), software (virtual task and feedback and presentation) intervention (progression and dose), and outcomes. Trends in the field were commented on, gaps in knowledge identified, and areas of future research and translation of VR to practice were suggested.

Robots integrated with virtual reality simulations for customized motor training in a person with upper extremity hemiparesis: a case study.

BACKGROUND AND PURPOSE: A majority of studies examining repetitive task practice facilitated by robots for the treatment of upper extremity paresis utilize standardized protocols applied to large groups. Others utilize interventions tailored to patients but do not describe the clinical decision-making process utilized to develop and modify interventions. This case study describes a robot-based intervention customized to match the goals and clinical presentation of person with upper extremity hemiparesis secondary to stroke. METHODS: The patient, P.M., was an 85-year-old man with left hemiparesis secondary to an intracerebral hemorrhage 5 years prior to examination. Outcomes were measured before and after a 1-month period of home therapy and after a 1-month robotic intervention. The intervention was designed to address specific impairments identified during his physical therapy examination. When necessary, activities were modified on the basis of response to the first week of treatment. OUTCOMES: P.M. trained in 12 sessions, using six virtually simulated activities. Modifications to original configurations of these activities resulted in performance improvements in five of these activities. P.M. demonstrated a 35-second improvement in Jebsen Test of Hand Function time and a 44-second improvement in Wolf Motor Function Test time subsequent to the robotic training intervention. Reaching kinematics, 24-hour activity measurement, and scores on the Hand and Activities of Daily Living scales of the Stroke Impact Scale all improved as well. DISCUSSION: A customized program of robotically facilitated rehabilitation was associated with short-term improvements in several measurements of upper extremity function in a patient with chronic hemiparesis.

Correlations between statistical models of robotically collected kinematics and clinical measures of upper extremity function.

One of the obstacles in the development of rehabilitation robotics has been inadequacy in the measurement of treatment effects due to interventions. A measurement tool that will efficiently produce a large reliable sample of measurements collected during a single session that can also produce a rich set of data which reflects a subject's ability to perform meaningful functional activities has not been developed. This paper presents three linear regression models generated from seven kinematic measures collected during the performance of virtually simulated rehabilitation activities that were integrated with haptic robots by 19 persons with upper extremity hemiparesis due to chronic stroke. One of these models demonstrated a statistically significant correlation with the subjects' scores on the Jebsen Test of Hand Function (JTHF), a battery of six standardized upper extremity functional activities. The second and third models demonstrated a statistically significant correlation with the subjects' change scores on the JTHF.

Robotically facilitated virtual rehabilitation of arm transport integrated with finger movement in persons with hemiparesis.

BACKGROUND: Recovery of upper extremity function is particularly recalcitrant to successful rehabilitation. Robotic-assisted arm training devices integrated with virtual targets or complex virtual reality gaming simulations are being developed to deal with this problem. Neural control mechanisms indicate that reaching and hand-object manipulation are interdependent, suggesting that training on tasks requiring coordinated effort of both the upper arm and hand may be a more effective method for improving recovery of real world function. However, most robotic therapies have focused on training the proximal, rather than distal effectors of the upper extremity. This paper describes the effects of robotically-assisted, integrated upper extremity training. METHODS: Twelve subjects post-stroke were trained for eight days on four upper extremity gaming simulations using adaptive robots during 2-3 hour sessions. RESULTS: The subjects demonstrated improved proximal stability, smoothness and efficiency of the movement path. This was in concert with improvement in the distal kinematic measures of finger individuation and improved speed. Importantly, these changes were accompanied by a robust 16-second decrease in overall time in the Wolf Motor Function Test and a 24-second decrease in the Jebsen Test of Hand Function. CONCLUSIONS: Complex gaming simulations interfaced with adaptive robots requiring integrated control of shoulder, elbow, forearm, wrist and finger movements appear to have a substantial effect on improving hemiparetic hand function. We believe that the magnitude of the changes and the stability of the patient's function prior to training, along with maintenance of several aspects of the gains demonstrated at retention make a compelling argument for this approach to training.

Learning in a virtual environment using haptic systems for movement re-education: can this medium be used for remodeling other behaviors and actions?

Robotic systems that are interfaced with virtual reality gaming and task simulations are increasingly being developed to provide repetitive intensive practice to promote increased compliance and facilitate better outcomes in rehabilitation post-stroke. A major development in the use of virtual environments (VEs) has been to incorporate tactile information and interaction forces into what was previously an essentially visual experience. Robots of varying complexity are being interfaced with more traditional virtual presentations to provide haptic feedback that enriches the sensory experience and adds physical task parameters. This provides forces that produce biomechanical and neuromuscular interactions with the VE that approximate real-world movement more accurately than visual-only VEs, simulating the weight and force found in upper extremity tasks. The purpose of this article is to present an overview of several systems that are commercially available for ambulation training and for training movement of the upper extremity. We will also report on the system that we have developed (NJIT-RAVR system) that incorporates motivating and challenging haptic feedback effects into VE simulations to facilitate motor recovery of the upper extremity post-stroke. The NJIT-RAVR system trains both the upper arm and the hand. The robotic arm acts as an interface between the participants and the VEs, enabling multiplanar movements against gravity in a three-dimensional workspace. The ultimate question is whether this medium can provide a motivating, challenging, gaming experience with dramatically decreased physical difficulty levels, which would allow for participation by an obese person and facilitate greater adherence to exercise regimes.

A comparison of motor adaptations to robotically facilitated upper extremity task practice demonstrated by children with cerebral palsy and adults with stroke.

Nine children with cerebral palsy and nine adults with stroke were trained using 5 different upper extremity simulations using the NJIT-RAVR system for approximately nine to twelve hours over a three week period. Both groups made improvements in clinical measurements of upper extremity function and reaching kinematics. Patterns and magnitudes of improvement differ between the two groups. Responses to training required adjustment of the robotic system to accommodate the rehabilitation needs of children with cerebral palsy.

Haptically facilitated bimanual training combined with augmented visual feedback in moderate to severe hemiplegia.

This study describes the design and feasibility testing of a hand rehabilitation system that provides haptic assistance for hand opening in moderate to severe hemiplegia while subjects attempt to perform bilateral hand movements. A cable-actuated exoskeleton robot assists the subjects in performing impaired finger movements but is controlled by movement of the unimpaired hand. In an attempt to combine the neurophysiological stimuli of bilateral movement and action observation during training, visual feedback of the impaired hand is replaced by feedback of the unimpaired hand, either by using a sagittaly oriented mirror or a virtual reality setup with a pair of virtual hands presented on a flat screen controlled with movement of the unimpaired hand, providing a visual image of their paretic hand moving normally. Joint angles for both hands are measured using data gloves. The system is programmed to maintain a symmetrical relationship between the two hands as they respond to commands to open and close simultaneously. Three persons with moderate to severe hemiplegia secondary to stroke trained with the system for eight, 30 to 60 minute sessions without adverse events. Each demonstrated positive motor adaptations to training. The system was well tolerated by persons with moderate to severe upper extremity hemiplegia. Further testing of its effects on motor ability with a broader range of clinical presentations is indicated.