Computer-Assisted Motivating Rehabilitation (CAMR) for Institutional, Home, and Educational Late Stroke Programs

Effects of a remote-handling-concept-based task-oriented arm training (ReHab-TOAT) on arm-hand skill performance in chronic stroke: a study protocol for a two-armed randomized controlled trial

BACKGROUND

Improving arm-hand skill performance is a major therapeutic target in stroke rehabilitation and needs intensive and varied training. However, guided treatment time is limited. Technology can assist in the training of patients, offering a higher intensity and more variety in content. A new task-oriented arm training approach was developed, using a 'Remote Handling concept based' device to provide haptic feedback during the performance of daily living activities (ReHab-TOAT). This study aims to investigate the effects of ReHab-TOAT on patients' arm-hand function and arm-hand skill performance, quality of life of both patients in the chronic phase after stroke and their caregivers and the patients' perception regarding the usability of the intervention.

METHODS

A randomized clinical trial was designed. Adult chronic stroke patients suffering from hemiparesis and arm-hand problems, with an Utrechtse Arm-hand Test score of 1-3, will be invited to participate. Participants in the experimental group receive ReHab-TOAT additional to care as usual. ReHab-TOAT contains task-oriented arm training for stroke patients in combination with haptic feedback, generated by a remote handling device. They will train for 4 weeks, 3× per week, 1.5h per day. Participants in the control group will receive no additional therapy apart from care as usual. The Fugl-Meyer Assessment (FMA), measuring participants' motor performance of the affected arm, is used as the primary outcome measure. Secondary outcome measures are arm-hand capacity of the patient (ARAT), perceived arm-hand skill performance (MAL), actual arm-hand skill performance (accelerometry), patients' quality of life (EuoQol-5D) and caregivers' quality of life (CarerQoL). Participants' perception regarding the usability of the intervention, including both the developed approach and technology used, will be evaluated by the System Usability Scale and a questionnaire on the user experience of technology. Measurements will be performed at 1, 2, 3 and 4 weeks pre-intervention (baseline); immediately post-intervention; and 3, 6 and 9 months post-intervention. Statistical analysis includes linear mixed model analysis.

DISCUSSION

This study is designed to investigate the evidence regarding the effects of ReHab-TOAT on patients' performance at different levels of the International Classification of Functioning, disability and health (ICF) model, i.e. a framework measuring functioning and disability in relation to a health condition, and to provide insights on a successful development and research process regarding technology-assisted training in co-creation.

TRIAL REGISTRATION

Netherlands Trial Register NL9541. Registered on June 22, 2021.

Virtual reality interventions to enhance upper limb motor improvement after a stroke: commonly used types of platform and outcomes

Introduction: Virtual Reality (VR) based platforms are useful in enhancing post-stroke sub-optimal upper limb (UL) motor improvement. A variety of options are available from expensive highly customizable platforms to low cost turnkey solutions. Clinical outcomes primarily help assess the effects of VR-based platforms. These outcomes mainly quantify how much improvement has occurred. Very few outcomes characterize the type (i.e. how) of recovery. We categorized the types of VR-based platforms and outcome measures commonly used for post-stroke UL motor improvement.Methods: We reviewed the published literature in English from 2000-2019. Different types of VR-based platforms were grouped into those available commercially and those developed by the various research groups. We initially classified outcomes from the retrieved studies under the appropriate International Classification of Functioning categories. Then, we divided the outcomes as those quantifying the type or extent of improvement.Results: We found a total of 125 studies. Majority of the studies used commercially available platforms. A total of 42 different outcome measures were used. Seventeen different outcomes were used to assess body structure and functions as well as in activity limitations. Eight outcomes assessed the effects of contextual factors and participation restrictions. The Fugl Meyer Assessment, Wolf Motor Function Test and Stroke Impact Scale were most often used across the three categories. Of the 125 studies, 52 used outcomes characterizing the type of recovery. Although a smaller proportion, 24 studies included movement patterns outcomes.Conclusion: A standardized set of outcomes can promote better comparisons between studies using different VR-based platforms for post-stroke UL motor improvement.Implications for RehabilitationA wide variety of commercially available systems are present from expensive customizable systems to low-cost turnkey systems.The Fugl-Meyer Assessment and Wolf Motor Function Test along with the Stroke Impact Scale-Social Participation subscale were used most often across all studies as assessments of body structure and function, activity limitations and participation restriction.It is essential to include movement pattern outcomes addressing whether recovery of compensation occurs with the use of VR-based platforms.

A natural user interface to integrate citizen science and physical exercise

Citizen science enables volunteers to contribute to scientific projects, where massive data collection and analysis are often required. Volunteers participate in citizen science activities online from their homes or in the field and are motivated by both intrinsic and extrinsic factors. Here, we investigated the possibility of integrating citizen science tasks within physical exercises envisaged as part of a potential rehabilitation therapy session. The citizen science activity entailed environmental mapping of a polluted body of water using a miniature instrumented boat, which was remotely controlled by the participants through their physical gesture tracked by a low-cost markerless motion capture system. Our findings demonstrate that the natural user interface offers an engaging and effective means for performing environmental monitoring tasks. At the same time, the citizen science activity increases the commitment of the participants, leading to a better motion performance, quantified through an array of objective indices. The study constitutes a first and necessary step toward rehabilitative treatments of the upper limb through citizen science and low-cost markerless optical systems.

Applicability of a motor rehabilitation system in stroke victims

Abstract Introduction: The recovery of stroke patients is long and boring due to the repetitive nature of the exercises used and the length of treatment. Thus, we started using virtual reality as an alternative and, because of its advantages, health professionals are adapting video games for physical therapy. However, there are some limitations, such as the fact that games are designed for entertainment and not for therapeutic purposes. Objective: In order to mitigate gaps in assistive devices for physical therapy, this study describes the development and applicability of a computer support system for motor rehabilitation - Ikapp - in stroke victims. Methods: Twenty-seven stroke patients filled out a socioeconomic questionnaire, tested Ikapp during five minutes and answered a usability and satisfaction questionnaire about handling the tool. The chi-square test was used to analyze any association between sociodemographic factors and the features of the system. Results: The Ikapp system can be an excellent device to assist neurological rehabilitation of stroke patients, as participants questionnaires showed that 85.2% were satisfied in regard to motivation and inclusion of Ikapp in physiotherapy and 77.8% relative to ease of interaction with the tool. Conclusion: The Ikapp system proved to be an easy-to-use and accessible computer support system for patients with functional limitations.

Assessment and Training in a 3-Dimensional Virtual Environment With Haptics: A Report on 5 Cases of Motor Rehabilitation in the Chronic Stage After Stroke

Objective. This exploratory study assessed the possible effectiveness of hemiparetic upper extremity training in subjects with chronic stroke with computer instrumentation (haptic force feedback) and 3-dimensional visualization applied to computer games, as well as to evaluate concurrent computer-assisted assessment of the kinematics of movements and test whether any improvement detected in the computer environment was reflected in activities of daily living (ADLs).

Methods. A single-subject repeated-measures experimental design (AB) was used. After baseline testing, 5 patients were assigned to the therapy 3 times a week for 45 min for 5 weeks. Velocity, time needed to reach, and hand path ratio (reflecting superfluous movements) were the outcome measures, along with the Assessment of Motor and Process Skills and the Box and Block test. The follow-up phase (C) occurred 12 weeks later.

Results. Improvements were noted in velocity, time, and hand path ratio. One patient showed improvement in occupational performance in ADLs.

Conclusions.The application of this strategy of using virtual reality (VR) technologies may be useful in assessing and training stroke patients. The results of this study must be reproduced in further studies. The VR systems can be placed in homes or other nonclinical settings.

Computer game-based upper extremity training in the home environment in stroke persons: a single subject design

BACKGROUND

The objective of the present study was to assess whether computer game-based training in the home setting in the late phase after stroke could improve upper extremity motor function.

METHODS

Twelve subjects with prior stroke were recruited; 11 completed the study.

DESIGN

The study had a single subject design; there was a baseline test (A1), a during intervention test (B) once a week, a post-test (A2) measured directly after the treatment phase, plus a follow-up (C) 16-18 weeks after the treatment phase. Information on motor function (Fugl-Meyer), grip force (GrippitR) and arm function in activity (ARAT, ABILHAND) was gathered at A1, A2 and C. During B, only Fugl-Meyer and ARAT were measured. The intervention comprised five weeks of game-based computer training in the home environment. All games were designed to be controlled by either the affected arm alone or by both arms. Conventional formulae were used to calculate the mean, median and standard deviations. Wilcoxon's signed rank test was used for tests of dependent samples. Continuous data were analyzed by methods for repeated measures and ordinal data were analyzed by methods for ordered multinomial data using cumulative logistic models. A p-value of < 0.05 was considered statistically significant.

RESULTS

Six females and five males, participated in the study with an average age of 58 years (range 26-66). FMA-UE A-D (motor function), ARAT, the maximal grip force and the mean grip force on the affected side show significant improvements at post-test and follow-up compared to baseline. No significant correlation was found between the amount of game time and changes in the outcomes investigated in this study.

CONCLUSION

The results indicate that computer game-based training could be a promising approach to improve upper extremity function in the late phase after stroke, since in this study, changes were achieved in motor function and activity capacity.

Eliciting Upper Extremity Purposeful Movements Using Video Games

Background. Video games have become popular in stroke rehabilitation; however, the nature of this intervention is not fully understood. Objectives. To compare the number of ( a) purposeful and nonpurposeful repetitions of the weaker upper extremity (UE) and ( b) movement accelerations as assessed by accelerometer activity counts of the weaker and stronger UEs of individuals with chronic stroke while playing video games or participating in traditional therapy. Methods. Twenty-nine individuals (mean age 59 years, 1-7 years poststroke) took part in a group intervention of video -games (n = 15) or traditional therapy (n = 14) as part of a randomized controlled trial. During 1 - 2 sessions, participants were video-taped while wearing wrist accelerometers. Assessors counted the number of repetitions and classified movements as purposeful or nonpurposeful using videotapes. The weaker UE motor impairments were correlated to movement accelerations, to determine if participants were using their potential during the sessions. Results. Participants in the video game group performed a median of 271 purposeful movements and 37 970 activity counts compared to 48 purposeful movements and 14 872 activity counts in the traditional group ( z = −3.0, P = .001 and z = −1.9, P = .05, respectively). Participants in the traditional group performed a median of 26 nonpurposeful (exercises) compared with 0 in the video game group ( z = −4.2, P = .000). Strong significant correlations were found between the motor ability of the weak UE to repetitions of participants in both groups ( r = .86, P < .01). Participants with higher motor ability performed more repetitions. Conclusions. Video games elicited more UE purposeful repetitions and higher acceleration of movement compared with traditional therapy in individuals with chronic stroke.

A Kinect-based upper limb rehabilitation system to assist people with cerebral palsy

This study assessed the possibility of rehabilitating two adolescents with cerebral palsy (CP) using a Kinect-based system in a public school setting. The system provided 3 degrees of freedom for prescribing a rehabilitation program to achieve customized treatment. This study was carried out according to an ABAB reversal replication design in which A represented the baseline and B represented intervention phases. Data showed that the two participants significantly increased their motivation for upper limb rehabilitation, thus improving exercise performance during the intervention phases. Practical and developmental implications of the findings are discussed.

A Kinect-based system for physical rehabilitation: a pilot study for young adults with motor disabilities

This study assessed the possibility of rehabilitating two young adults with motor impairments using a Kinect-based system in a public school setting. This study was carried out according to an ABAB sequence in which A represented the baseline and B represented intervention phases. Data showed that the two participants significantly increased their motivation for physical rehabilitation, thus improving exercise performance during the intervention phases. Practical and developmental implications of the findings are discussed.

Stroke Therapy through Motion-Based Games

In the United States alone, more than five million people are living with long term motor impairments caused by a stroke. Recently, video games with affordable motion-based input devices have been proposed as a part of therapy to help people recover lost range of motion and motor control. While researchers have demonstrated the potential utility of therapeutic games through controlled studies, relatively little work has explored their long-term home-based use. We conducted a six-week home study with a 62-year-old woman who was seventeen years post-stroke. She played therapeutic games for approximately one hour a day, five days a week. Over the six weeks, she recovered significant motor abilities, which is unexpected given the time since her stroke. We explore detecting such improvements early, using game logs for daily measurements of motor ability to complement the standard measurements that are taken less often. Through observations and interviews, we present lessons learned about the barriers and opportunities that arise from long-term home-based use of therapeutic games.

Use of computer games as an intervention for stroke

Current rehabilitation for persons with hemiparesis after stroke requires high numbers of repetitions to be in accordance with contemporary motor learning principles. The motivational characteristics of computer games can be harnessed to create engaging interventions for persons with hemiparesis after stroke that incorporate this high number of repetitions. The purpose of this case report was to test the feasibility of using computer games as a 6-week home therapy intervention to improve upper extremity function for a person with stroke. One person with left upper extremity hemiparesis after stroke participated in a 6-week home therapy computer game intervention. The games were customized to her preferences and abilities and modified weekly. Her performance was tracked and analyzed. Data from pre-, mid-, and postintervention testing using standard upper extremity measures and the Reaching Performance Scale (RPS) were analyzed. After 3 weeks, the participant demonstrated increased upper extremity range of motion at the shoulder and decreased compensatory trunk movements during reaching tasks. After 6 weeks, she showed functional gains in activities of daily living (ADLs) and instrumental ADLs despite no further improvements on the RPS. Results indicate that computer games have the potential to be a useful intervention for people with stroke. Future work will add additional support to quantify the effectiveness of the games as a home therapy intervention for persons with stroke.

Advances in upper limb stroke rehabilitation: a technology push

Strokes affect thousands of people worldwide leaving sufferers with severe disabilities affecting their daily activities. In recent years, new rehabilitation techniques have emerged such as constraint-induced therapy, biofeedback therapy and robot-aided therapy. In particular, robotic techniques allow precise recording of movements and application of forces to the affected limb, making it a valuable tool for motor rehabilitation. In addition, robot-aided therapy can utilise visual cues conveyed on a computer screen to convert repetitive movement practice into an engaging task such as a game. Visual cues can also be used to control the information sent to the patient about exercise performance and to potentially address psychosomatic variables influencing therapy. This paper overviews the current state-of-the-art on upper limb robot-mediated therapy with a focal point on the technical requirements of robotic therapy devices leading to the development of upper limb rehabilitation techniques that facilitate reach-to-touch, fine motor control, whole-arm movements and promote rehabilitation beyond hospital stay. The reviewed literature suggest that while there is evidence supporting the use of this technology to reduce functional impairment, besides the technological push, the challenge ahead lies on provision of effective assessment of outcome and modalities that have a stronger impact transferring functional gains into functional independence.

Quantifying learned non-use after stroke using unilateral and bilateral steering tasks

Learned non-use (LNU) is common after stroke and manifests when persons with stroke spontaneously use their stronger less-impaired arm despite residual functional abilities in the impaired arm. This tendency of under utilizing the impaired arm slows down the re-acquisition of bilateral coordination on activities of daily living. We wanted to examine whether this behavior could be studied and quantified using the TheraDrive system, a low-cost, mechatronic/robotic stroke rehabilitation system which uses a commercial force-feedback steering wheel along with custom games and unilateral and bilateral steering tasks for therapy and assessment. We attempt to quantify the role of the impaired arm in bilateral tracking with one and two-wheeled modes of the TheraDrive. Our results indicate that impaired arm use, arm bias and learned non-use behaviors may best be detected in decoupled bilateral tracking tasks.

Mina: A Sensorimotor Robotic Orthosis for Mobility Assistance

While most mobility options for persons with paraplegia or paraparesis employ wheeled solutions, significant adverse health, psychological, and social consequences result from wheelchair confinement. Modern robotic exoskeleton devices for gait assistance and rehabilitation, however, can support legged locomotion systems for those with lower extremity weakness or paralysis. The Florida Institute for Human and Machine Cognition (IHMC) has developed the Mina, a prototype sensorimotor robotic orthosis for mobility assistance that provides mobility capability for paraplegic and paraparetic users. This paper describes the initial concept, design goals, and methods of this wearable overground robotic mobility device, which uses compliant actuation to power the hip and knee joints. Paralyzed users can balance and walk using the device over level terrain with the assistance of forearm crutches employing a quadrupedal gait. We have initiated sensory substitution feedback mechanisms to augment user sensory perception of his or her lower extremities. Using this sensory feedback, we hypothesize that users will ambulate with a more natural, upright gait and will be able to directly control the gait parameters and respond to perturbations. This may allow bipedal (with minimal support) gait in future prototypes.

Low-cost monitoring of patients during unsupervised robot/computer assisted motivating stroke rehabilitation

There is a need for effective stroke rehabilitation systems that can be used in undersupervised/unsupervised environments such as the home to assist in improving and/or sustaining functional outcomes. We determined the stability, accuracy and usability of an extremely low-cost mobile robot for use with a robot/computer motivating rehabilitation device, TheraDrive. The robot provided cues to discourage excessive trunk movements and to encourage arm movements. The mobile robot system was positively received by potential users, and it was accurate and stable over time. Feedback from users suggests that finding the optimal frequency and type of encouragement and corrective feedback given by the robot helper will be critical for long-term acceptance.

The Rutgers Arm II rehabilitation system--a feasibility study

The Rutgers Arm II (RA II) is a new system that trains the shoulder/arm motor control, strengthening, arm speed of motion, endurance, and grasp strength in a single rehabilitation session. The system components are a tilted low-friction table, a forearm support with markers and wireless transmitter, a shoulder appendage to detect compensatory leaning, infrared vision tracking, a large display and a PC running custom virtual reality games. Three participants in the chronic stage post-stroke were trained on the RAII for four weeks (12 sessions) and had a follow-up evaluation after three months. The results of this study indicate that the participants were able to use the technology, and preliminary results are encouraging. One participant showed improvement in all timed Jebsen-Taylor test tasks, all participants had a larger shoulder range-of-motion and pinch strength of the affected hand post-training. Computerized measure of supported arm reach area increased in two participants post-training and in all participants at follow-up. Participants reported an improved ability to perform activities of daily living with the affected arm. There was good compliance by the participants, each of whom attended all sessions. The participants accepted the training length, even with some sessions lasting 1 h (excluding rest periods). The participants' subjective evaluation rated the system an average 3.7 out of 5 (see also the accompanying taped video interview of one of the participants).

Sensor-based arm skill training in chronic stroke patients: results on treatment outcome, patient motivation, and system usability

As stroke incidence increases, therapists' time is under pressure. Technology-supported rehabilitation may offer new opportunities. The objective of this study was to evaluate patient motivation for and the feasibility and effects of a new technology-supported task-oriented arm training regime (T-TOAT). Nine chronic stroke patients performed T-TOAT (2 x 30 min/day, four days/week) during eight weeks. A system including movement tracking sensors, exercise board, and software-based toolkit was used for skill training. Measures were recorded at baseline, after four and eight weeks of training, and six months posttraining. T-TOAT improved arm-hand performance significantly on Fugl-Meyer, Action Research Arm Test, and Motor Activity Log. Training effects lasted at least six months posttraining. Health-related-quality-of-life had improved significantly after eight weeks of T-TOAT with regard to perceived physical health, but not to perceived mental health (SF-36). None of the EuroQol-5D components showed significant differences before and after training. Participants were intrinsically motivated and felt competent to use the system. Furthermore, system usability was rated very good. However, exercise challenge as perceived by participants decreased significantly over eight weeks of training. The results of this study indicate that T-TOAT is feasible. Despite the small number of stroke patients tested, significant and clinically relevant improvements in skilled arm-hand performance were found.

Evaluation of the TheraDrive system for robot/computer assisted motivating rehabilitation after stroke

This paper presents experimental data evaluating the merits of using a fun and engaging therapy protocol over a less engaging one in the context of a low-cost robot/computer motivating rehabilitation system for stroke rehabilitation called TheraDrive. The preliminary results suggest that there is a small advantage of the engaging therapy over the rote therapy in reducing motor impairment, improving ADL function, and improving stability. The more engaging protocol has an advantage in maintaining engagement and interest in therapy.

A mobile robot therapist for under-supervised training with robot/computer assisted motivating systems

Robot assisted therapy is a new and promising area in stroke rehabilitation and has shown to be effective in reducing motor impairment, but is a costly solution for home rehabilitation. High medical costs could be reduced if we could improve rehabilitation exercise in unsupervised environments such as the home. Hence, there is an augmented need for a cost effective rehabilitation system that can be used outside the clinic. This paper presents the design concept for an autonomous robotic assistant that is low-cost and effective in engaging the users while assisting them with therapy in any under-supervised area. We investigated how the robot assistant can support TheraDrive, our low-cost therapy system. We present the design methods and a case study demonstrating the arm and video collection system.

Technology-assisted training of arm-hand skills in stroke: concepts on reacquisition of motor control and therapist guidelines for rehabilitation technology design

Background

It is the purpose of this article to identify and review criteria that rehabilitation technology should meet in order to offer arm-hand training to stroke patients, based on recent principles of motor learning.

Methods

A literature search was conducted in PubMed, MEDLINE, CINAHL, and EMBASE (1997–2007).

Results

One hundred and eighty seven scientific papers/book references were identified as being relevant. Rehabilitation approaches for upper limb training after stroke show to have shifted in the last decade from being analytical towards being focussed on environmentally contextual skill training (task-oriented training). Training programmes for enhancing motor skills use patient and goal-tailored exercise schedules and individual feedback on exercise performance. Therapist criteria for upper limb rehabilitation technology are suggested which are used to evaluate the strengths and weaknesses of a number of current technological systems.

Conclusion

This review shows that technology for supporting upper limb training after stroke needs to align with the evolution in rehabilitation training approaches of the last decade. A major challenge for related technological developments is to provide engaging patient-tailored task oriented arm-hand training in natural environments with patient-tailored feedback to support (re) learning of motor skills.

Contributions of Online Visual Feedback to the Learning and Generalization of Novel Finger Coordination Patterns

We explored how people learn new ways to move objects through space using neuromuscular control signals having more degrees of freedom than needed to unambiguously specify object location. Subjects wore an instrumented glove that recorded finger motions. A linear transformation matrix projected joint angle signals (a high-dimensional control vector) onto a two-dimensional cursor position on a video monitor. We assessed how visual information influences learning and generalization of novel finger coordination patterns as subjects practiced using hand gestures to manipulate cursor location. Three groups of test subjects practiced moving a visible cursor between different sets of screen targets. The hand-to-screen transformation was designed such that the different sets of targets (which we called implicit spatial cues) varied in how informative they were about the gestures to be learned. A separate control group practiced gesturing with explicit cues (pictures of desired gestures) without ongoing cursor feedback. Another control group received implicit spatial cueing and feedback only of final cursor position. We found that test subjects and subjects provided with explicit cues could learn to produce desired gestures, although training efficacy decreased as the amount of task-relevant feedback decreased. Although both control groups learned to associate screen targets with specific gestures, only subjects provided with online feedback of cursor motion learned to generalize in a manner consistent with the internal representation of an inverse hand-to-screen mapping. These findings suggest that spatial learning and generalization require dynamic feedback of object motion in response to control signal changes; static information regarding geometric relationships between controller and endpoint configurations does not suffice.

An interactive framework for personalized computer-assisted neurorehabilitation

This paper presents the implementation of a framework for computer-assisted neurorehabilitation that intends to address the need for more personalized healthcare technologies. This framework called UniTherapy is applied to home neurorehabilitation for individuals with stroke-induced disability. It supports interactive upper limb assessment and therapy that makes use of mass-marketed force-reflecting joysticks and wheels, as well as some customized therapeutic devices. A novel service-oriented technical infrastructure is presented, which includes a rich menu of performance assessment capabilities and support features that include telerehabilitation links, protocol design, and data analysis tools. Results are presented that demonstrate its potential as a sensor-based assessment tool. User feedback is summarized.

TheraDrive: a new stroke therapy concept for home-based, computer-assisted motivating rehabilitation

Stroke results in functional arm impairments that persist even after rehabilitation training. The increasing numbers of persons at-risk in the population for stroke creates an increased need for therapy programs that can be effectively administered in both home and outpatient clinics. The aim of this work is to create a low-cost, commercially-viable, home-based rehabilitation system that can capitalize on computer-assisted motivating rehabilitation concepts of game therapy and skill training with functional training related to real activities to induce user-dependent CNS plasticity. The TheraDrive concept combines the motivational elements of relearning steering tasks with playing driving video games using commercial force-feedback steering wheels to create an upper arm stroke therapy environment that is usable at home or in the clinic. This paper presents the concept and reports on investigations to evaluate the main commercial building blocks for the prototype: the steering wheel and driving software. Evaluation results of three force-feedback steering wheels and the driving gaming software called SmartDriver are presented. Future evaluation trials with stroke subjects will be completed.

Enhanced TheraJoy technology for use in upper-extremity stroke rehabilitation

Due to rising costs of health care and decreasing length of conventional therapy, it has become imperative to develop affordable, motivating devices that can be used in the home for upper-extremity stroke rehabilitation. In the TheraJoy project, a commercial joystick has been modified to enlarge the range of arm movement used during therapeutic movement tasks, and to support the application of light passive and actuated forces. The enhanced version presented here allows for motion in both the horizontal and vertical planes, uses a dynamic linkage model to map joystick-hand position and force data, uses motivating gaming technology, and can be used in both therapy and in home settings. This study compares performance and benefits of motion in the horizontal to vertical plane, evaluates user performance during assessment and therapy tasks, and documents user opinions of potential uses of this technology for stroke rehabilitation.

Potential of a suite of robot/computer-assisted motivating systems for personalized, home-based, stroke rehabilitation

Background

There is a need to improve semi-autonomous stroke therapy in home environments often characterized by low supervision of clinical experts and low extrinsic motivation. Our distributed device approach to this problem consists of an integrated suite of low-cost robotic/computer-assistive technologies driven by a novel universal access software framework called UniTherapy. Our design strategy for personalizing the therapy, providing extrinsic motivation and outcome assessment is presented and evaluated.

Methods

Three studies were conducted to evaluate the potential of the suite. A conventional force-reflecting joystick, a modified joystick therapy platform (TheraJoy), and a steering wheel platform (TheraDrive) were tested separately with the UniTherapy software. Stroke subjects with hemiparesis and able-bodied subjects completed tracking activities with the devices in different positions. We quantify motor performance across subject groups and across device platforms and muscle activation across devices at two positions in the arm workspace.

Results

Trends in the assessment metrics were consistent across devices with able-bodied and high functioning strokes subjects being significantly more accurate and quicker in their motor performance than low functioning subjects. Muscle activation patterns were different for shoulder and elbow across different devices and locations.

Conclusion

The Robot/CAMR suite has potential for stroke rehabilitation. By manipulating hardware and software variables, we can create personalized therapy environments that engage patients, address their therapy need, and track their progress. A larger longitudinal study is still needed to evaluate these systems in under-supervised environments such as the home.

Progress toward universal interface technologies for telerehabilitation

One of the overriding needs in the field of telerehabilitation is for user-centered interfaces that provide individuals with differing abilities with access to effective remote communication. This paper provides a foundation for developing and evaluating interfaces that move towards the aim of universal accessibility, and reports on progress for four types of interfaces: multimedia conferencing technologies involving persons with different roles and disabilities participating in goal-directed tasks; physical devices for therapy and assessment; communication/control for computer-assisted teletherapy; and an intelligent telerehabilitation assistant that supports the dynamic rehabilitative process.

Recent trends in robot-assisted therapy environments to improve real-life functional performance after stroke

Upper and lower limb robotic tools for neuro-rehabilitation are effective in reducing motor impairment but they are limited in their ability to improve real world function. There is a need to improve functional outcomes after robot-assisted therapy. Improvements in the effectiveness of these environments may be achieved by incorporating into their design and control strategies important elements key to inducing motor learning and cerebral plasticity such as mass-practice, feedback, task-engagement, and complex problem solving.

This special issue presents nine articles. Novel strategies covered in this issue encourage more natural movements through the use of virtual reality and real objects and faster motor learning through the use of error feedback to guide acquisition of natural movements that are salient to real activities. In addition, several articles describe novel systems and techniques that use of custom and commercial games combined with new low-cost robot systems and a humanoid robot to embody the " supervisory presence" of the therapy as possible solutions to exercise compliance in under-supervised environments such as the home.

Recovery from brain injury in animals: relative efficacy of environmental enrichment, physical exercise or formal training (1990-2002)

In the 1960s, it was shown for the first time that enriched housing enhances functional recovery after brain damage. During the 1970s and 1980s, many findings similar to this initial one have been reported, enlarging greatly its generality. Over the last 13 years, many different kinds of brain damage were modelled in animals or even directly studied in humans. Overall, these recent studies corroborated earlier findings, although occasional exceptions were reported. Other critical data, obtained mainly in intact animals, showed that enriched housing increases neurogenesis in the adult hippocampus. Recent evidence that this neurogenesis is involved in hippocampal-dependent learning supports the original interpretation of the enrichment effects as being the result of an accumulation of informal learning experiences (e.g., [. Heredity, environment, brain biochemistry, and learning. In: Current Trends in Psychological Theory. University of Pittsburgh Press, Pittsburgh, pp. 87-110;. Brain changes in response to experience. Sci. Am. 226, 22-29]). Other components of enriched environment, such as physical exercise, may have additive effects with those of training. The comparison of the relative effectiveness of enriched experience, of physical exercise and of training on structural and/or functional assessments of recovery, shows that training/learning is generally more effective than physical exercise and that enriched experience is a more potent therapy than either of these two other treatments. The combination of enriched experience with some other neurosurgical and/or neuropharmacological treatments may further improve its therapeutic effectiveness. Finally, other recent reports emphasize that the treatment parameters may be changed in order to approximate clinical/rehabilitation conditions and, nevertheless, remain effective.

Motivating, game-based stroke rehabilitation: a brief report

Stroke-induced hemiparesis is a debilitating impairment that compromises ability to perform many activities of daily living (ADLs). Many new therapies for hemiparesis, although intriguing, require exceptional patient motivation and/or may be difficult to implement in some clinical situations. This brief report revisits a motivating, game-based rehabilitation modality reported nearly three decades ago that has heretofore been ignored. Pilot data, examining the feasibility and efficacy of the device, are presented.

Late postacute neurologic rehabilitation: neuroscience, engineering, and clinical programs

This lecture highlights my career in rehabilitation research. My principal efforts in rehabilitation have been to study (1) mechanisms of brain plasticity related to reorganization of the brain and recovery of function; (2) late postacute rehabilitation; (3) sensory substitution; and (4) rehabilitation engineering. A principal goal has been to aid in the development of a strong scientific base in rehabilitation.