The influence of scaffolding on intrinsic motivation and autonomous adherence to a game-based, sparsely supervised home rehabilitation program for people with upper extremity hemiparesis due to stroke. A randomized controlled trial.

BACKGROUND: This parallel, randomized controlled trial examined intrinsic motivation, adherence and motor function improvement demonstrated by two groups of subjects that performed a 12-week, home-based upper extremity rehabilitation program. Seventeen subjects played scaffolded games, presenting eight to twelve discrete levels of increasing difficulty. Sixteen subjects performed the same activities controlled by success algorithms that modify game difficulty incrementally. METHODS: 33 persons 20-80 years of age, at least 6 months post stroke with moderate to mild hemiparesis were randomized using a random number generator into the two groups. They were tested using the Action Research Arm Test, Upper Extremity Fugl Meyer Assessment, Stroke Impact Scale and Intrinsic Motivation Inventory pre and post training. Adherence was measured using timestamps generated by the gaming system. Subjects had the Home Virtual Rehabilitation System (Qiu in J Neuroeng Rehabil 17: 1-10, 2020) placed in their homes and were taught to perform rehabilitation games using it. Subjects were instructed to train twenty minutes per day but were allowed to train as much as they chose. Subjects trained for 12 weeks without appointments and received intermittent support from study staff. Group outcomes were compared using ANOVA. Correlations between subject demographics and adherence, as well as motor outcome, were evaluated using Pearson Correlation Coefficients. RESULTS: There were 5 dropouts and no adverse events. The main effect of time was statistically significant for four of the five clinical outcome measures. There were no significant training group by time interactions. Measures of adherence did not differ significantly between groups. The combined groups improved their UEFMA scores on average by 5.85 (95% CI 4.73-6.98). 21 subjects from both groups demonstrating improvements in UEFMA scores of at least 5 points, exceeding the minimal clinically important difference of 4.25. IMI scores were stable pre to post training. CONCLUSIONS: Scaffolding challenges during game based rehabilitation did not elicit higher levels of adherence when compared to algorithm control of game difficulty. Both sparsely supervised programs of game-based treatment in the home were sufficient to elicit statistically significant, clinically meaningful improvements in motor function and activities of daily living. TRIAL REGISTRATION: Clinical Trials.gov-NCT03985761, Registered June 14, 2019.

A Review of the Use of Gaze and Pupil Metrics to Assess Mental Workload in Gamified and Simulated Sensorimotor Tasks.

Gaze and pupil metrics are used to represent higher cognitive processes in a variety of contexts. One growing area of research is the real-time assessment of workload and corresponding effort in gamified or simulated cognitive and motor tasks, which will be reviewed in this paper. While some measurements are consistent across studies, others vary and are likely dependent on the nature of the effort required by the task and the resulting changes in arousal. Pupil diameter is shown to consistently increase with task effort and arousal; however, the valence of arousal must be considered. In many cases, measures of pupil diameter were sensitive to both excessive and insufficient challenge. Overall, it is evident that gaze and pupil metrics are valuable to assess the cognitive state during gamified and simulated tasks, and further research is indicated regarding their use in clinical populations in rehabilitation to inform optimally engaging interventions.

Validation of the Kinematic Assessment Protocol Used in the Technology-Supported Neurorehabilitation System, Rehabilitation Technologies for Hand and Arm (R3THA™), in Children and Teenagers with Cerebral Palsy.

This study evaluates the R3THA™ assessment protocol (R3THA-AP™), a technology-supported testing module for personalized rehabilitation in children with cerebral palsy (CP). It focuses on the reliability and validity of the R3THA-AP in assessing hand and arm function, by comparing kinematic assessments with standard clinical assessments. Conducted during a 4-week summer camp, the study assessed the functional and impairment levels of children with CP aged 3-18. The findings suggest that R3THA is more reliable for children aged 8 and older, indicating that age significantly influences the protocol's effectiveness. The results also showed that the R3THA-AP's kinematic measurements of hand and wrist movements are positively correlated with the Box and Blocks Test Index (BBTI), reflecting hand function and dexterity. Additionally, the R3THA-AP's accuracy metrics for hand and wrist activities align with the Melbourne Assessment 2's Range of Motion (MA2-ROM) scores, suggesting a meaningful relationship between R3THA-AP data and clinical assessments of motor skills. However, no significant correlations were observed between the R3THA-AP and MA2's accuracy and dexterity measurements, indicating areas for further research. These findings validate the R3THA-AP's utility in assessing motor abilities in CP patients, supporting its integration into clinical practice.

Laboratory-Based Examination of the Reliability and Validity of Kinematic Measures of Wrist and Finger Function Collected by a Telerehabilitation System in Persons with Chronic Stroke.

We have developed the New Jersey Institute of Technology-Home Virtual Rehabilitation System (NJIT-HoVRS) to facilitate intensive, hand-focused rehabilitation in the home. We developed testing simulations with the goal of providing richer information for clinicians performing remote assessments. This paper presents the results of reliability testing examining differences between in-person and remote testing as well as discriminatory and convergent validity testing of a battery of six kinematic measures collected with NJIT-HoVRS. Two different groups of persons with upper extremity impairments due to chronic stroke participated in two separate experiments. Data Collection: All data collection sessions included six kinematic tests collected with the Leap Motion Controller. Measurements collected include hand opening range, wrist extension range, pronation-supination range, hand opening accuracy, wrist extension accuracy, and pronation-supination accuracy. The system usability was evaluated by therapists performing the reliability study using the System Usability Scale. When comparing the in-laboratory collection and the first remote collection, the intra-class correlation coefficients (ICC) for three of the six measurements were above 0.900 and the other three were between 0.500 and 0.900. Two of the first remote collection/second remote collection ICCs were above 0.900, and the other four were between 0.600 and 0.900. The 95% confidence intervals for these ICC were broad, suggesting that these preliminary analyses need to be confirmed by studies with larger samples. The therapist's SUS scores ranged from 70 to 90. The mean was 83.1 (SD = 6.4), which is consistent with industry adoption. There were statistically significant differences in the kinematic scores when comparing unimpaired and impaired UE for all six measures. Five of six impaired hand kinematic scores and five of six impaired/unimpaired hand difference scores demonstrated correlations between 0.400 and 0.700 with UEFMA scores. Reliability for all measures was acceptable for clinical practice. Discriminant and convergent validity testing suggest that scores on these tests may be meaningful and valid. Further testing in a remote setting is necessary to validate this process.

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.

Intensive virtual reality and robotic based upper limb training compared to usual care, and associated cortical reorganization, in the acute and early sub-acute periods post-stroke: a feasibility study.

BACKGROUND: There is conflict regarding the benefits of greater amounts of intensive upper limb rehabilitation in the early period post-stroke. This study was conducted to test the feasibility of providing intensive therapy during the early period post-stroke and to develop a randomized control trial that is currently in process. Specifically, the study investigated whether an additional 8 h of specialized, intensive (200-300 separate hand or arm movements per hour) virtual reality (VR)/robotic based upper limb training introduced within 1-month post-stroke resulted in greater improvement in impairment and behavior, and distinct changes in cortical reorganization measured via Transcranial Magnetic Stimulation (TMS), compared to that of a control group. METHODS: Seven subjects received 8-1 h sessions of upper limb VR/robotic training in addition to their inpatient therapy (PT, OT, ST). Six subjects only received their inpatient therapy. All were tested on measures of impairment [Upper Extremity Fugl-Meyer Assessment (UEFMA), Wrist AROM, Maximum Pinch Force], behavior [Wolf Motor Function Test (WMFT)], and also received TMS mapping until 6 months post training. ANOVAs were conducted to measure differences between groups across time for all outcome measures. Associations between changes in ipsilesional cortical maps during the early period of enhanced neuroplasticity and long-term changes in upper limb impairment and behavior measures were evaluated. RESULTS: The VR/robotic group made significantly greater improvements on UEFMA and Wrist AROM scores compared to the usual care group. There was also less variability in the association between changes in the First Dorsal Interosseus (FDI) muscle map area and WMFT and Maximum Force change scores for the VR/robotic group. CONCLUSIONS: An additional 8 h of intensive VR/robotic based upper limb training initiated within the first month post-stroke may promote greater gains in impairment compared to usual care alone. Importantly, the data presented demonstrated the feasibility of conducting this intervention and multiple outcome measures (impairment, behavioral, neurophysiological) in the early period post-stroke.

The JFK BIG study: the impact of LSVT BIG® on dual task walking and mobility in persons with Parkinson's disease.

[Purpose] The aim of this study was to test the hypothesis that Lee Silverman Voice Treatment-BIG decreases the negative impact of hypokinesia on dual task performance in persons with Parkinson's disease. [Subjects and Methods] The records of 114 patients with Parkinson's admitted to outpatient rehabilitation at a suburban hospital were reviewed. Demographics and data for 8 outcome measures were extracted for subjects that completed 14 of 16 sessions of BIG. 93 of these subjects had records of pre and post-test Timed Up and Go, Timed Up and Go Motor, and Timed Up and Go Cognitive scores. Average age was 68.4 years (SD=10.6) and average disease duration was 4.9 years (SD=5.3). [Results] Subjects demonstrated statistically significant improvements for Timed Up and Go (3.3 SD=4.5), Timed Up and Go Motor (4.4 SD=5.8) and Timed Up and Go Cognitive (4.7 SD=5.4). Concurrent motor and cognitive performance remained stable. Dual task cost decreased at a statistically significant level for Timed Up and Go Cognitive (7% SD=31%) but not Motor (4% SD=32%). [Conclusion] These findings suggest that cueing strategies associated with LSVT BIG become internalized and decrease the negative impact of hypokinesia on mobility and cognitive performance while performing two tasks simultaneously in persons with Parkinson's.

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.

The influence of scaffolding on intrinsic motivation and autonomous adherence to a game-based, unsupervised home rehabilitation program for people with upper extremity hemiparesis due to stroke. A randomized controlled trial.

Background: This parallel, randomized controlled trial examines intrinsic motivation, adherence and motor function improvement demonstrated by two groups of subjects that performed a twelve-week, home-based upper extremity rehabilitation program. Seventeen subjects played games presenting eight to twelve discrete levels of increasing difficulty. Sixteen subjects performed the same activities controlled by success algorithms that modify game difficulty incrementally. Methods: 33 persons 20 to 80 years of age, at least six months post stroke with moderate to mild hemiparesis were randomized using a random number generator into the two groups. They were tested using the Action Research Arm Test, Upper Extremity Fugl Meyer Assessment, Stroke Impact Scale and Intrinsic Motivation Inventory pre and post training. Adherence was measured using timestamps generated by the system. Subjects had the Home Virtual Rehabilitation System [1]systems placed in their homes and were taught to perform rehabilitation games using it. Subjects were instructed to train twenty minutes per day but were allowed to train as much as they chose. Subjects trained for twelve weeks without appointments and received intermittent support from study staff. Group outcomes were compared using ANOVA. Correlations between subject demographics and adherence, as well as motor outcome, were evaluated using Pearson Correlation Coefficients. Classification and Regression Tree (CART) models were generated to predict responders using demographics and baseline measures. Results: There were 5 dropouts and no adverse events. The main effect of time was statistically significant for four of the five clinical outcome measures. There were no significant training group by time interactions. Measures of adherence did not differ between groups. 21 subjects from both groups, demonstrated clinically important improvements in UEFMA score of at least 4.25 points. Subjects with pre training UEFMA scores below 53.5 averaged a seven-point UEFMA increase. IMI scores were stable pre to post training. Conclusions: Scaffolding did not have a meaningful impact on adherence or motor function improvement. A sparsely supervised program of game-based treatment in the home was sufficient to elicit meaningful improvements in motor function and activities of daily living. Common factors considered barriers to the utilization of telerehabilitation did not impact adherence or motor outcome. Trial registration: Clinical Trials.gov - NCT03985761, Registered June 14, 2019.

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.

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.

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.

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.

Virtual Rehabilitation of the Paretic Hand and Arm in Persons With Stroke: Translation From Laboratory to Rehabilitation Centers and the Patient's Home.

The anatomical and physiological heterogeneity of strokes and persons with stroke, along with the complexity of normal upper extremity movement make the possibility that any single treatment approach will become the definitive solution for all persons with upper extremity hemiparesis due to stroke unlikely. This situation and the non-inferiority level outcomes identified by many studies of virtual rehabilitation are considered by some to indicate that it is time to consider other treatment modalities. Our group, among others, has endeavored to build on the initial positive outcomes in studies of virtual rehabilitation by identifying patient populations, treatment settings and training schedules that will best leverage virtual rehabilitation's strengths. We feel that data generated by our lab and others suggest that (1) persons with stroke may adapt to virtual rehabilitation of hand function differently based on their level of impairment and stage of recovery and (2) that less expensive, more accessible home based equipment seems to be an effective alternative to clinic based treatment that justifies continued optimism and study.

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.

Sensorimotor training in virtual reality: a review.

Recent experimental evidence suggests that rapid advancement of virtual reality (VR) technologies has great potential for the development of novel strategies for sensorimotor training in neurorehabilitation. We discuss what the adaptive and engaging virtual environments can provide for massive and intensive sensorimotor stimulation needed to induce brain reorganization.Second, discrepancies between the veridical and virtual feedback can be introduced in VR to facilitate activation of targeted brain networks, which in turn can potentially speed up the recovery process. Here we review the existing experimental evidence regarding the beneficial effects of training in virtual environments on the recovery of function in the areas of gait,upper extremity function and balance, in various patient populations. We also discuss possible mechanisms underlying these effects. We feel that future research in the area of virtual rehabilitation should follow several important paths. Imaging studies to evaluate the effects of sensory manipulation on brain activation patterns and the effect of various training parameters on long term changes in brain function are needed to guide future clinical inquiry. Larger clinical studies are also needed to establish the efficacy of sensorimotor rehabilitation using VR in various clinical populations and most importantly, to identify VR training parameters that are associated with optimal transfer to real-world functional improvements.

The New Jersey Institute of Technology Robot-Assisted Virtual Rehabilitation (NJIT-RAVR) system for children with cerebral palsy: a feasibility study.

BACKGROUND: We hypothesize that the integration of virtual reality (VR) with robot assisted rehabilitation could be successful if applied to children with hemiparetic CP. The combined benefits of increased attention provided by VR and the larger training stimulus afforded by adaptive robotics may increase the beneficial effects of these two approaches synergistically. This paper will describe the NJIT-RAVR system, which combines adaptive robotics with complex VR simulations for the rehabilitation of upper extremity impairments and function in children with CP and examine the feasibility of this system in the context of a two subject training study. METHODS: The NJIT-RAVR system consists of the Haptic Master, a 6 degrees of freedom, admittance controlled robot and a suite of rehabilitation simulations that provide adaptive algorithms for the Haptic Master, allowing the user to interact with rich virtual environments. Two children, a ten year old boy and a seven year old girl, both with spastic hemiplegia secondary to Cerebral Palsy were recruited from the outpatient center of a comprehensive pediatric rehabilitation facility. Subjects performed a battery of clinical testing and kinematic measurements of reaching collected by the NJIT-RAVR system. Subjects trained with the NJIT-RAVR System for one hour, 3 days a week for three weeks. The subjects played a combination of four or five simulations depending on their therapeutic goals, tolerances and preferences. Games were modified to increase difficulty in order to challenge the subjects as their performance improved. The testing battery was repeated following the training period. RESULTS: Both participants completed 9 hours of training in 3 weeks. No untoward events occurred and no adverse responses to treatment or complaints of cyber sickness were reported. One participant showed improvements in overall performance on the functional aspects of the testing battery. The second subject made improvements in upper extremity active range of motion and in kinematic measures of reaching movements. CONCLUSION: We feel that this study establishes the feasibility of integrating robotics and rich virtual environments to address functional limitations and decreased motor performance in children with mild to moderate cerebral palsy.

Design of a complex virtual reality simulation to train finger motion for persons with hemiparesis: a proof of concept study.

BACKGROUND: Current neuroscience has identified rehabilitation approaches with the potential to stimulate adaptive changes in the brains of persons with hemiparesis. These approaches include, intensive task-oriented training, bimanual activities and balancing proximal and distal upper extremity interventions to reduce competition between these segments for neural territory. METHODS: This paper describes the design and feasibility testing of a robotic/virtual environment system designed to train the hand and arm of persons with hemiparesis. The system employs a simulated piano that presents visual, auditory and tactile feedback comparable to an actual piano. Arm tracking allows patients to train both the arm and hand as a coordinated unit, emphasizing the integration of both transport and manipulation phases. The piano trainer includes songs and scales that can be performed with one or both hands. Adaptable haptic assistance is available for more involved subjects. An algorithm adjusts task difficulty in proportion to subject performance. A proof of concept study was performed on four subjects with upper extremity hemiparesis secondary to chronic stroke to establish: a) the safety and feasibility of this system and b) the concurrent validity of robotically measured kinematic and performance measures to behavioral measures of upper extremity function. RESULTS: None of the subjects experienced adverse events or responses during or after training. As a group, the subjects improved in both performance time and key press accuracy. Three of the four subjects demonstrated improvements in fractionation, the ability to move each finger individually. Two subjects improved their aggregate time on the Jebsen Test of Hand Function and three of the four subjects improved in Wolf Motor Function Test aggregate time. CONCLUSION: The system designed in this paper has proven to be safe and feasible for the training of hand function for persons with hemiparesis. It features a flexible design that allows for the use and further study of adjustments in point of view, bilateral and unimanual treatment modes, adaptive training algorithms and haptically rendered collisions in the context of rehabilitation of the hemiparetic hand.

The Association Between Reorganization of Bilateral M1 Topography and Function in Response to Early Intensive Hand Focused Upper Limb Rehabilitation Following Stroke Is Dependent on Ipsilesional Corticospinal Tract Integrity.

Transcranial magnetic stimulation (TMS) induced motor evoked potentials (MEPs) are an established proxy of corticospinal excitability. As a binary measure, the presence (MEP+) or absence (MEP-) of ipsilesional hemisphere MEPs early following stroke is a robust indicator of long-term recovery, however this measure does not provide information about spatial cortical reorganization. MEPs have been systematically acquired over the sensorimotor cortex to "map" motor topography. In this investigation we compared the degree to which functional improvements resulting from early (<3 months post-stroke) intensive hand focused upper limb rehabilitation correlate with changes in motor topography between MEP+ and MEP- individuals. Following informed consent, 17 individuals (4 Female, 60.3 ± 9.4 years, 24.6 ± 24.01 days post first time stroke) received 8 one hour-sessions of training with virtual reality (VR)/Robotic simulations. Clinical tests [Box and Blocks Test (BBT), Wolf Motor Function Test (WMFT), Upper Extremity Fugl-Meyer (UEFMA)], kinematic and kinetic assessments [finger Active Range of Motion (finger AROM), Maximum Pinch Force (MPF)], and bilateral TMS mapping of 5 hand muscles were performed prior to (PRE), directly following (POST), and 1 month following (1M) training. Participants were divided into two groups (MEP+, MEP-) based on whether an MEP was present in the affected first dorsal interosseous (FDI) at any time point. MEP+ individuals improved significantly more than MEP- individuals from PRE to 1M on the WMFT, BBT, and finger AROM scores. Ipsilesional hemisphere FDI area increased significantly with time in the MEP+ group. FDI area of the contralesional hemisphere was not significantly different across time points or groups. In the MEP+ group, significant correlations were observed between PRE-1M changes in ipsilesional FDI area and WMFT, BBT, and finger AROM, and contralesional FDI area and UEFMA and MPF. In the MEP- group, no significant correlations were found between changes in contralesional FDI area and functional outcomes. We report preliminary evidence in a small sample that patterns of recovery and the association of recovery to bilateral changes in motor topography may depend on integrity of the ipsilesional cortical spinal tract as assessed by the presence of TMS evoked MEPs.