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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 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.

In this chapter, the experiences of four subjects from a larger trial of video game-based hand and arm rehabilitation for stroke survivors are discussed. We will outline the barriers to participation and adherence to home programs for persons with stroke and relate them to the use of previously developed New Jersey Institute of Technology Home Virtual Rehabilitation System (NJIT-HoVRS), developed to address these barriers. Next we discuss describe the experiences of participants. The four subjects represent the highest and lowest levels of adherence in their protocol groups. Interestingly, more commonalities are observed between the two higher adhering and the two lower adhering subjects than there are when comparing subjects across the two protocols utilized in the study. Age, computer literacy and previous experience with computer games did not have a consistent impact on adherence in these subjects. Moreover, all four subjects demonstrated “clinically significant improvements” in motor function, but only one expressed satisfaction with the outcome. This initial examination suggests that maximizing adherence across a broad sample of subjects might not be achieved an intervention that addresses a set of diagnosis- or population-specific barriers to participation.

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.

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.

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 (

Introduction: Several large trials of task based rehabilitation examining interventions designed to meet the main tenets of experience-dependent neuroplasticity have failed to identify an approach to rehabilitation that produces improvements in hand function that consistently returns persons with stroke to their pre-stroke levels of activity and participation. Several scholars have identified the heightened levels of neuroplasticity occurring immediately after a stroke as an important opportunity to present rehabilitation interventions that will optimize the functional recovery. The study described in this paper begins to examine whether the heightened plasticity occurring early after stroke, when combined with intense technology based upper extremity training, will have a more positive impact than the spontaneous recovery process on its own, or similar interventions presented later, on the long-term recovery of hand and arm function. We hypothesized that early training would allow subjects to integrate their recovering motor abilities into higher levels of activity level performance and that this early integration would result in higher levles of activity level function normalized for impairment level at retention.

Several approaches to rehabilitation of the hand following a stroke have emerged over the last two decades. These treatments, including repetitive task practice (RTP), robotically assisted rehabilitation and virtual rehabilitation activities, produce improvements in hand function but have yet to reinstate function to pre-stroke levels—which likely depends on developing the therapies to impact cortical reorganization in a manner that favors or supports recovery. Understanding cortical reorganization that underlies the above interventions is therefore critical to inform how such therapies can be utilized and improved and is the focus of the current investigation. Specifically, we compare neural reorganization elicited in stroke patients participating in two interventions: a hybrid of robot-assisted virtual reality (RAVR) rehabilitation training and a program of RTP training. Ten chronic stroke subjects participated in eight 3-h sessions of RAVR therapy. Another group of nine stroke subjects participated in eight sessions of matched RTP therapy. Functional magnetic resonance imaging (fMRI) data were acquired during paretic hand movement, before and after training. We compared the difference between groups and sessions (before and after training) in terms of BOLD intensity, laterality index of activation in sensorimotor areas, and the effective connectivity between ipsilesional motor cortex (iMC), contralesional motor cortex, ipsilesional primary somatosensory cortex (iS1), ipsilesional ventral premotor area (iPMv), and ipsilesional supplementary motor area. Last, we analyzed the relationship between changes in fMRI data and functional improvement measured by the Jebsen Taylor Hand Function Test (JTHFT), in an attempt to identify how neurophysiological changes are related to motor improvement. Subjects in both groups demonstrated motor recovery after training, but fMRI data revealed RAVR-specific changes in neural reorganization patterns. First, BOLD signal in multiple regions of interest was reduced and re-lateralized to the ipsilesional side. Second, these changes correlated with improvement in JTHFT scores. Our findings suggest that RAVR training may lead to different neurophysiological changes when compared with traditional therapy. This effect may be attributed to the influence that augmented visual and haptic feedback during RAVR training exerts over higher-order somatosensory and visuomotor areas.

Current service delivery models limit treatment time and length of hospital stay during the period of post-ischemic heightened neuronal plasticity when intensive training may optimally affect recovery. Prioritization for rehabilitation of independence in transfers and ambulation, negatively impacts the provision of intensive hand and upper extremity therapy. Our pilot data show that we are able to integrate intensive, targeted hand therapy that uses robotics and a library of gaming activities into the routine of an acute rehabilitation setting. Our system has been specifically designed to deliver hand training when motion and strength are limited. The system uses adaptive algorithms to drive individual finger movement, gain adaptation and workspace modification, and haptic and visual feedback from mirrored movements. The data establishes a foundation for a future clinical trial to investigate the potential benefits of robot-assisted gaming during the early phase of recovery.

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.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.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.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.

To investigate the ability of the New Jersey Institute of Technology Robot Assisted Virtual Rehabilitation (NJIT-RAVR) system training to elicit changes in upper extremity (UE) function in children with hemiplegia secondary to cerebral palsy.Nine children (mean age 9 years, three males) participated in three pilots. Subjects trained 1 hour, 3 days a week for 3 weeks. Two groups performed this protocol as their only intervention. The third group also performed 5-6 hours of constraint-induced movement therapy.All subjects participated in a short programme of nine, 60-minute training sessions without adverse effects. As a group, subjects demonstrated statistically significant improvements in Melbourne Assessment of Unilateral Upper Limb Function Test, a composite of three timed UE tasks and several measurements of reaching kinematics. Several subjects demonstrated clinically significant improvements in active shoulder abduction and flexion as well as forearm supination.Three small pilots of NJIT-RAVR training demonstrated measurable benefit with no complications, warranting further examination.

Rehabilitation of individuals with flaccid or severely affected upper extremities is challenging due to their limited motor ability and few options for therapeutic training. This initial study tested the feasibility of training individuals with severe hemiparesis using virtual reality (VR) based mirrored feedback and pinch force modulation tasks. The results demonstrated that the simulations were well tolerated early after stroke. Priming effects of the mirror tasks were suggested by increased maximal pinch force immediately after training. Furthermore, despite having no clinically observable movement distally, the subjects were able to consciously activate their muscles as shown by force traces and EMG recorded during the pinch trace task. Motor learning was also suggested by the decrease in Root Mean Square Error (RMSE) during this task. Lastly the benefits of using objective, technology based measurement tools was demonstrated by the ability of the force sensor to detect small changes in force production that could not be measured with a clinical scale of impairment.

The need to quickly discharge patients following stroke from acute rehabilitation facilities to the home has resulted in an intense focus on restoring safe and independent, if not normal, motor function. Rehabilitation of hand function in patients with upper limb impairment is often de-prioritized to allow for an emphasis on practicing activities necessary for a safe discharge to the home, such as walking and bed mobility. This case study describes a patient with slow recovering hand motor function (hand sub-section of Fugl-Meyer examination score = 2 on post-stroke day 37) following a stroke. The patient received an intensive eight-session intervention that focused on the recovery of finger extension, finger individuation and pinch-grasp force modulation as well as the recovery of proximal upper extremity movement. Over the eight sessions, the patient demonstrated a dramatic increase in hand function and a 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. Gains in motor control transferred to clinically meaningful hand function measured at the activity level.

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.

Objective: This study describes the analysis of hand preshaping using Linear Discriminant Analysis (LDA) to predict hand formation during reaching and grasping tasks of the hemiparetic hand, following a series of upper extremity motor intervention treatments. The purpose of this study is to use classification of hand posture as an additional tool for evaluating the effectiveness of therapies for upper extremity rehabilitation such as virtual reality (VR) therapy and conventional physical therapy. Classification error for discriminating between two objects during hand preshaping is obtained for the hemiparetic and unimpaired hands pre and post training. Methods: Eight subjects post stroke participated in a two-week training session consisting of upper extremity motor training. Four subjects trained with interactive VR computer games and four subjects trained with clinical physical therapy procedures of similar intensity. Subjects' finger joint angles were measured during a kinematic reach to grasp test using CyberGlove® and arm joint angles were measured using the trackSTAR™ system prior to training and after training. Results: The unimpaired hand of subjects preshape into the target object with greater accuracy than the hemiparetic hand as indicated by lower classification errors. Hemiparetic hand improved in preshaping accuracy and time to reach minimum error. Conclusion: Classification of hand preshaping may provide insight into improvements in motor performance elicited by robotically facilitated virtually simulated training sessions or conventional physical therapy.

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.

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.

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. The feasibility of this system is examined in the context of two pilot studies. The NJIT-RAVR system consists of the Haptic Master, a 6 degrees of freedom, admittance controlled robot and a suite of rehabilitation simulations that we have developed. The system provides adaptive algorithms for the Haptic Master, allowing impaired users to interact with rich virtual environments. All subjects trained with the NJIT-RAVR System for one hour, 3 days a week for three weeks. Both groups improved in robotically collected kinematic measures and the Melbourne Assessment of Unilateral Upper Limb Function.

Recent discoveries demonstrate that the brain can be remodeled after stroke, principally through new synaptic generation. Task-specific & repetitive training are critical factors in promoting this synaptic generation & are central components in rehabilitation of upper extremity (UE) motor weakness following stroke. Virtual reality (VR) based therapy have been shown to be effective at facilitating specific & consistently repetitive movements during training. In combination with robotics the nature of the training can be further tailored to fit the patient's rehabilitative needs. This paper describes the design & consideration of The Blood Cell Game, a new VR game used in UE stroke rehabilitation in the New Jersey Institute of Technology robot assisted virtual reality training system (RAVR).

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. The feasibility of this system is examined in the context of two pilot studies. The NJIT-RAVR system consists of the Haptic Master, a 6 degrees of freedom, admittance controlled robot and a suite of rehabilitation simulations that we have developed. The system provides adaptive algorithms for the Haptic Master, allowing impaired users to interact with rich virtual environments. All 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. Subjects differed in the level of activity performed outside of NJIT-RAVR system training. Each group of subjects performed a battery of clinical testing and kinematic measurements of reaching collected by the NJIT-RAVR system. Both groups improved in robotically collected kinematic measures and the Melbourne Assessment of Unilateral Upper Limb Function.

We describe the design and testing of a system that integrates rich virtual environments and assist as needed robotics to allow children with upper extremity impairments to perform rehabilitation activities in the form of computer games. Five simulations as well as positioning and interface approaches are described. To provide proof of concept we trained four children with mild to moderate upper extremity hemiplegia secondary to cerebral palsy. The children made improvements in clinical measures of upper extremity function and reaching kinematics as measured by the robot.

Various authors have described pre and post testing improvements in upper limb coordination as a result of intensive upper limb interventions. While the ability to alter coordination patterns as a result of repetitive hand-arm movement is established, patterns of change in the relationship between proximal and distal effectors of the UE over the course of multiple sessions of training have not been described in the rehabilitation literature. In this study eight subjects (5 male, 3 female) with a mean age of 56.4 years (SD=14.2) and a mean time since CVA of 54.7 months post-stroke (SD=51.7) were trained for eight, 2–3 hour sessions on four robotically facilitated virtual rehabilitation activities. This paper will present 1) Functional performance and pre and post testing kinematic analysis for the eight subjects 2) More extensive analysis of the change in hand and arm coordination over the course of the eight session intervention demonstrated by one of the subjects from this sample 3) Kinematic analysis of another subject from this sample performing an un-trained reaching and grasping activity, before and after training.

We have previously designed a virtual reality-based training system for hand rehabilitation. Here we report the design of an extended version of the system that allows training of the hemiparetic arm and hand during one training session, and provides haptic assistance during hand motion and during arm movements in three-dimensional space. It also allows bimanual training of the hand and arm. Hand training was based on a virtual piano activity that was designed to promote finger range of motion and independence. Hand exercises included reaching to stationary and moving targets presented in stereo. The use of a three-dimensional robot based on admittance control allowed the use of active force applied by the subject as an input to the haptic controller. Two stroke survivors were trained for three weeks using computer gamelike activities. Subjects improved on movement kinematics and on several of the clinical tests.

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. Electronic supplementary material The online version of this article (doi:10.1186/1743-0003-11-126) contains supplementary material, which is available to authorized users.

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.

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.

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.