Robotic Table and Serious Games for Integrative Rehabilitation in the Early Poststroke Phase: Two Case Reports.

BACKGROUND: BrightArm Compact is a new rehabilitation system for the upper extremities. It provides bimanual training with gradated gravity loading and mediates interactions with cognitively challenging serious games. OBJECTIVE: The aim of this study is to design and test a robotic rehabilitation table-based virtual rehabilitation system for functional impact of the integrative training in the early poststroke phase. METHODS: A new robotic rehabilitation table, controllers, and adaptive games were developed. The 2 participants underwent 12 experimental sessions in addition to the standard of care. Standardized measures of upper extremity function (primary outcome), depression, and cognition were administered before and after the intervention. Nonstandardized measures included game variables and subjective evaluations. RESULTS: The 2 case study participants attained high total arm repetitions per session (504 and 957) and achieved high grasp and finger-extension counts. Training intensity contributed to marked improvements in affected shoulder strength (225% and 100% increase), grasp strength (27% and 16% increase), and pinch strength (31% and 15% increase). The shoulder flexion range increased by 17% and 18% and elbow supination range by 75% and 58%. Improvements in motor function were at or above minimal clinically important difference for the Fugl-Meyer Assessment (11 and 10 points), Chedoke Arm and Hand Activity Inventory (11 and 14 points), and Upper Extremity Functional Index (19 and 23 points). Cognitive and emotive outcomes were mixed. Subjective rating by participants and training therapists were positive (average 4, SD 0.22, on a 5-point Likert scale). CONCLUSIONS: The design of the robotic rehabilitation table was tested on 2 participants in the early poststroke phase, and results are encouraging for upper extremity functional gains and technology acceptance. TRIAL REGISTRATION: ClinicalTrials.gov NCT04252170; https://clinicaltrials.gov/ct2/show/NCT04252170.

Novel integrative rehabilitation system for the upper extremity: Design and usability evaluation.

PURPOSE: Design and test the usability of a novel virtual rehabilitation system for bimanual training of gravity supported arms, pronation/supination, grasp strengthening, and finger extension. METHODS: A robotic rehabilitation table, therapeutic game controllers, and adaptive rehabilitation games were developed. The rehabilitation table lifted/lowered and tilted up/down to modulate gravity loading. Arms movement was measured simultaneously, allowing bilateral training. Therapeutic games adapted through a baseline process. Four healthy adults performed four usability evaluation sessions each, and provided feedback using the USE questionnaire and custom questions. Participant's game play performance was sampled and analyzed, and system modifications made between sessions. RESULTS: Participants played four sessions of about 50 minutes each, with training difficulty gradually increasing. Participants averaged a total of 6,300 arm repetitions, 2,200 grasp counts, and 2,100 finger extensions when adding counts for each upper extremity. USE questionnaire data averaged 5.1/7 rating, indicative of usefulness, ease of use, ease of learning, and satisfaction with the system. Subjective feedback on the custom evaluation form was 84% favorable. CONCLUSIONS: The novel system was well-accepted, induced high repetition counts, and the usability study helped optimize it and achieve satisfaction. Future studies include examining effectiveness of the novel system when training patients acute post-stroke.

Assistive game controller for artificial intelligence-enhanced telerehabilitation post-stroke.

Off-the-shelf gaming technology is designed for young, fit, and motor intact individuals. Artificial intelligence (AI) has a role in making controllers and therapeutic games adaptable to the disabled. Post-stroke rehabilitation outcomes can be enhanced by gaming technology within the home to enable engaging telerehabilitation. BrightBrainer™ Grasp (BBG) is a novel therapeutic game controller designed to adapt to arm and hand impairments post-stroke. It mediates intensive arm reach, grasp and finger extension training and has the ability to track relevant outcomes. The newly designed controller uses BrightBrainer gamification system with AI technology to provide automatic adaptation, requiring minimal clinician input. This article describes the BBG design, hardware, force and movement detection and calibration, and its integration with the therapeutic games. The use of AI in adapting a library of custom therapeutic games is also described. Results of a usability study with healthy individuals and related design modifications are presented, with implications for future trials.

A Randomized Feasibility Trial of a Novel, Integrative, and Intensive Virtual Rehabilitation Program for Service Members Post-Acquired Brain Injury.

INTRODUCTION: Acquired Brain Injury, whether resulting from Traumatic brain injury (TBI) or Cerebral Vascular Accident (CVA), represent major health concerns for the Department of Defense and the nation. TBI has been referred to as the "signature" injury of recent U.S. military conflicts in Iraq and Afghanistan - affecting approximately 380,000 service members from 2000 to 2017; whereas CVA has been estimated to effect 795,000 individuals each year in the United States. TBI and CVA often present with similar motor, cognitive, and emotional deficits; therefore the treatment interventions for both often overlap. The Defense Health Agency and Veterans Health Administration would benefit from enhanced rehabilitation solutions to treat deficits resulting from acquired brain injuries (ABI), including both TBI and CVA. The purpose of this study was to evaluate the feasibility of implementing a novel, integrative, and intensive virtual rehabilitation system for treating symptoms of ABI in an outpatient clinic. The secondary aim was to evaluate the system's clinical effectiveness. MATERIALS AND METHODS: Military healthcare beneficiaries with ABI diagnoses completed a 6-week randomized feasibility study of the BrightBrainer Virtual Rehabilitation (BBVR) system in an outpatient military hospital clinic. Twenty-six candidates were screened, consented and randomized, 21 of whom completed the study. The BBVR system is an experimental adjunct ABI therapy program which utilizes virtual reality and repetitive bilateral upper extremity training. Four self-report questionnaires measured participant and provider acceptance of the system. Seven clinical outcomes included the Fugl-Meyer Assessment of Upper Extremity, Box and Blocks Test, Jebsen-Taylor Hand Function Test, Automated Neuropsychological Assessment Metrics, Neurobehavioral Symptom Inventory, Quick Inventory of Depressive Symptomatology-Self-Report, and Post Traumatic Stress Disorder Checklist- Civilian Version. The statistical analyses used bootstrapping, non-parametric statistics, and multilevel/hierarchical modeling as appropriate. This research was approved by the Walter Reed National Military Medical Center and Uniformed Services University of the Health Sciences Institutional Review Boards. RESULTS: All of the participants and providers reported moderate to high levels of utility, ease of use and satisfaction with the BBVR system (x- = 73-86%). Adjunct therapy with the BBVR system trended towards statistical significance for the measure of cognitive function (ANAM [x- = -1.07, 95% CI -2.27 to 0.13, p = 0.074]); however, none of the other effects approached significance. CONCLUSION: This research provides evidence for the feasibility of implementing the BBVR system into an outpatient military setting for treatment of ABI symptoms. It is believed these data justify conducting a larger, randomized trial of the clinical effectiveness of the BBVR system.

Feasibility of integrative games and novel therapeutic game controller for telerehabilitation of individuals chronic post-stroke living in the community.

BACKGROUND: Intensive, adaptable and engaging telerehabilitation is needed to enhance recovery and maximize outcomes. Such services may be provided under early supported discharge, or later for chronic populations. A novel virtual reality game-based telerehabilitation system was designed for individuals post-stroke to enhance their bimanual upper extremity motor function, cognition, and wellbeing. OBJECTIVES: To evaluate the feasibility of novel therapeutic game controller and telerehabilitation system for home use. METHODS: Individuals chronic post-stroke and their caregivers were recruited (n = 8 + 8) for this feasibility study. One was a screen failure and seven completed 4 weeks (20 sessions) of home-based therapy with or without remote monitoring. Standardized clinical outcome measures were taken pre- and post-therapy. Game performance outcomes were sampled at every session, while participant and caregiver subjective evaluations were done weekly. RESULTS: There was a 96% rate of compliance to protocol, resulting in an average of 13,000 total arm repetitions/week/participant. Group analysis showed significant (p <.05) improvements in grasp strength (effect size [ES] = 0.15), depression (Beck Depression Inventory II, ES = 0.75), and cognition (Neuropsychological Assessment Battery for Executive Function, ES = 0.46). Among the 49 outcome variables, 36 variables (73.5%) improved significantly (p = .001, binomial sign test). Technology acceptance was very good with system rating by participants at 3.7/5 and by caregivers at 3.5/5. CONCLUSIONS: These findings indicate the feasibility and efficacy of the system in providing home-based telerehabilitation. The BrightBrainer system needs to be further evaluated in randomized control trials and with individuals early post-stroke.

A feasibility study to determine the benefits of upper extremity virtual rehabilitation therapy for coping with chronic pain post-cancer surgery.

BACKGROUND: Persistent pain in shoulder and arm following post-surgical breast cancer treatment can lead to cognitive and physical deficits. Depression is also common in breast cancer survivors. Virtual reality therapy with integrative cognitive and physical rehabilitation has not been clinically trialed for this population. The novel BrightArm Duo technology improved cognition and upper extremity (UE) function for other diagnoses and has great potential to benefit individuals coping with post-surgical breast cancer pain. OBJECTIVES: The aim of this study was to explore the feasibility of BrightArm Duo therapy for coping with post-surgical chronic pain and associated disability in breast cancer survivors with depression. METHODS: BrightArm Duo is a robotic rehabilitation table modulating gravity loading on supported forearms. It tracks arm position and grasping strength while patients play three-dimensional (3D) custom integrative rehabilitation games. Community-dwelling women (N = 6) with post-surgical breast cancer pain in the upper arm trained on the system twice a week for 8 weeks. Training difficulty increased progressively in game complexity, table tilt and session length (20-50 minutes). Standardized assessments were performed before and after therapy for pain, cognition, emotion, UE function and activities of daily living. RESULTS: Subjects averaged upwards of 1300 arm repetitions and 850 hand grasps per session. Pain intensity showed a 20% downward trend (p = 0.1) that was corroborated by therapist observations and participant feedback. A total of 10 out of 11 cognitive metrics improved post-training (p = 0.01) with a significant 8.3-point reduction in depression severity (p = 0.04). A total of 17 of 18 range of motion metrics increased (p < 0.01), with five affected-side shoulder improvements above the Minimal Clinically Important Difference (8°). In all, 13 out of 15 strength and function metrics improved (p = 0.02) with lateral deltoid strength increasing 7.4 N on the affected side (p = 0.05). CONCLUSION: This pilot study demonstrated feasibility of using the BrightArm Duo Rehabilitation System to treat cancer survivors coping with upper body chronic pain. Outcomes indicate improvement in cognition, shoulder range, strength, function and depression.

A Rehabilitation First-Tournament Between Teams of Nursing Home Residents with Chronic Stroke.

PURPOSE: This study describes the BrightArm™ Duo virtual reality system (Bright Cloud International Corp., Highland Park, NJ) and determines its clinical benefit for maintenance of upper extremity function in nursing home residents who are chronic poststroke. MATERIALS AND METHODS: Participants sat at a low-friction robotic table with tilt and lift capability and interacted with serious games through computerized supports that measured forearm movement and grasp. The rehabilitation simulations were designed to improve arm and hand function, increase range of motion, and improve emotional well-being and cognition (attention, memory, and executive functioning). After 8 weeks of initial intensive therapy, there were three booster periods at 8-week intervals, each consisting of four sessions over 2 weeks. The last booster was a tournament competition, where pairs of residents played games collaboratively from remote nursing homes. Participants were evaluated before and after each booster period using standardized clinical measures. RESULTS: Range of motion improved for 18 out of 23 upper extremity movement variables (P = 0.01) between pre- and post-tournament assessment, and the residents self-reported that they enjoyed playing with a partner (score of 4.7 out of 5.0). Participants were able to reduce game completion time through cooperative play (teamwork), and the times improved with successive sessions of the tournament. Affected hand and arm function and depression levels were maintained (no decline) after the tournament. CONCLUSIONS: A rehabilitation tournament using virtual reality between teams of nursing home residents chronic poststroke is the first of its kind in clinical practice. This study demonstrates its effectiveness in improving range of motion of the upper extremity while engaging residents in the maintenance program at their nursing home.

Feasibility study of the BrightBrainer™ integrative cognitive rehabilitation system for elderly with dementia.

PURPOSE: To describe the development of BrightBrainer™ integrative cognitive rehabilitation system and determine clinical feasibility with nursing home-bound dementia patients. METHOD: BrightBrainer cognitive rehabilitation simulations were first played uni-manually, then bimanually. Participants sat in front of a laptop and interacted through a game controller that measured hand movements in 3D, as well as flexion of both index fingers. Interactive serious games were designed to improve basic and complex attention (concentration, short-term memory, dual tasking), memory recall, executive functioning and emotional well-being. Individual simulations adapted automatically to each participant's level of motor functioning. The system underwent feasibility trials spanning 16 sessions over 8 weeks. Participants were evaluated pre- and post-intervention, using standardized neuropsychological measures. Computerized measures of movement repetitions and task performance were stored on a remote server. RESULTS: Group analysis for 10 participants showed statistically significant improvement in decision making (p < 0.01), with trend improvements in depression (p < 0.056). Improvements were also seen in processing speed (p < 0.13) and auditory attention (p < 0.17); however, these were not statistically significant (partly attributable to the modest sample size). Eight of nine neuropsychological tests showed changes in the improvement direction indicating an effective rehabilitation (p < 0.01). BrightBrainer technology was well tolerated with mean satisfaction ratings of 4.9/5.0 across participants. CONCLUSIONS: Preliminary findings demonstrate utility within an advanced dementia population, suggesting that it will be beneficial to evaluate BrightBrainer through controlled clinical trials and to investigate its application in other clinical populations. Implications for Rehabilitation It is possible to improve cognitive function in older low-functioning patients. Integrative rehabilitation through games combining cognitive (memory, focusing, executive function) and physical (bimanual whole arm movement, grasping, task sequencing) elements is enjoyable for this population. The severity of depression in these elderly can be reduced through virtual reality bimanual games. The number of upper extremity active repetitions performed in the process of solving cognitive problems with the BrightBrainer™ system is 600. This number is 18 times (1875%) larger than those observed by other researchers in conventional physical or occupational rehabilitation sessions.

Novel integrative virtual rehabilitation reduces symptomatology of primary progressive aphasia--a case report.

PURPOSE: BrightBrainer™ integrative cognitive rehabilitation system evaluation in an Adult Day Program by a subject with Primary Progressive Aphasia (PPA) assumed to be of the mixed nonfluent/logopenic variant, and for determination of potential benefits. METHODS: The subject was a 51-year-old Caucasian male diagnosed with PPA who had attended an Adult Day Program for 18 months prior to BrightBrainer training. The subject interacted with therapeutic games using a controller that measured 3D hand movements and flexion of both index fingers. The computer simulations adapted difficulty level based on task performance; results were stored on a remote server. The clinical trial consisted of 16 sessions, twice/week for 8 weeks. The subject was evaluated through neuropsychological measures, therapy notes and caregiver feedback forms. RESULTS: Neuropsychological testing indicated no depression (BDI 0) and severe dementia (BIMS 1 and MMSE 3). The 6.5 h of therapy consisted of games targeting Language comprehension; Executive functions; Focusing; Short-term memory; and Immediate/working memory. The subject attained the highest difficulty level in all-but-one game, while averaging 1300-arm task-oriented active movement repetitions and 320 index finger flexion movements per session. While neuropsychological testing showed no benefits, the caregiver reported strong improvements in verbal responses, vocabulary use, speaking in complete sentences, following one-step directions and participating in daily activities. This corroborated well with therapy notes. CONCLUSIONS: Preliminary findings demonstrate a meaningful reduction of PPA symptoms for the subject, suggesting follow-up imaging studies to detail neuronal changes induced by BrightBrainer system and controlled studies with a sufficiently large number of PPA subjects.

Robotics and gaming to improve ankle strength, motor control, and function in children with cerebral palsy--a case study series.

The objective of this study was to investigate the feasibility of game-based robotic training of the ankle in children with cerebral palsy (CP). The design was a case study, 12 weeks intervention, with no follow-up. The setting was a university research laboratory. The participants were a referred sample of three children with cerebral palsy, age 7-12, all male. All completed the intervention. Participants trained on the Rutgers Ankle CP system for 36 rehabilitation sessions (12 weeks, three times/week), playing two custom virtual reality games. The games were played while participants were seated, and trained one ankle at-a-time for strength, motor control, and coordination. The primary study outcome measures were for impairment (DF/PF torques, DF initial contact angle and gait speed), function (GMFM), and quality of life (Peds QL). Secondary outcome measures relate to game performance (game scores as reflective of ankle motor control and endurance). Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. Game performance improved in both games during the intervention. This feasibility study supports the assumption that game-based robotic training of the ankle benefits gait in children with CP. Game technology is appropriate for the age group and was well accepted by the participants. Additional studies are needed however, to quantify the level of benefit and compare the approach presented here to traditional methods of therapy.

Integrative rehabilitation of elderly stroke survivors: the design and evaluation of the BrightArm™.

PURPOSE: To describe the development of the BrightArm upper extremity rehabilitation system, and to determine its clinical feasibility with older hemiplegic patients. METHOD: The BrightArm adjusted arm gravity loading through table tilting. Patients wore an arm support that sensed grasp strength and communicated wirelessly with a personal computer. Games were written to improve cognitive, psychosocial and the upper extremity motor function and adapted automatically to each patient. The system underwent feasibility trials spanning 6 weeks. Participants were evaluated pre-therapy, post-therapy, and at 6 weeks follow-up using standardized clinical measures. Computerized measures of supported arm reach and game performance were stored on a remote server. RESULTS: Five participants had clinically significant improvements in their active range of shoulder movement, shoulder strength, grasp strength, and their ability to focus. Several participants demonstrated substantially higher arm function (measured with the Fugl-Meyer test) and two were less-depressed (measured with the Becks Depression Inventory, Second Edition). The BrightArm technology was well-accepted by the participants, who gave it an overall subjective rating of 4.1 on a 5 point Likert scale. CONCLUSIONS: Given these preliminary findings, it will be beneficial to evaluate the BrightArm through controlled clinical trials and to investigate its application to other clinical populations.

Maintained hand function and forearm bone health 14 months after an in-home virtual-reality videogame hand telerehabilitation intervention in an adolescent with hemiplegic cerebral palsy.

Virtual reality videogames can be used to motivate rehabilitation, and telerehabilitation can be used to improve access to rehabilitation. These uses of technology to improve health outcomes are a burgeoning area of rehabilitation research. So far, there is a lack of reports of long-term outcomes of these types of interventions. The authors report a 15-year-old boy with hemiplegic cerebral palsy and epilepsy because of presumed perinatal stroke who improved his plegic hand function and increased his plegic forearm bone health during a 14-month virtual reality videogame hand telerehabilitation intervention. A total of 14 months after the intervention ended, repeat evaluation demonstrated maintenance of both increased hand function and forearm bone health. The implications of this work for the future of rehabilitation in children with neurological disabilities are discussed in this article.

Ankle control and strength training for children with cerebral palsy using the Rutgers Ankle CP: a case study.

The purpose of the study described here was to develop and feasibility test the Rutgers Ankle CP, aimed at ankle strengthening and improved control for children with cerebral palsy (CP). The system was an upgrade in hardware (new foot attachment, new robot controller) and software (new games and programming language) of the earlier Rutgers Ankle in order to permit training of children with CP. The new Rutgers Ankle CP was used to train ankle strength and motor control in a 7 year old boy with CP during 36 rehabilitation sessions (12 weeks, 3 times/week). Assessments for impairment, function and quality of life were taken before and after training. Results indicated improvements in both strength and motor control. Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. While these results are only for a single participant, they are very encouraging toward improving the function and quality of life of children with cerebral palsy. Further research with a larger number of participants is planned.

Long-term hand tele-rehabilitation on the PlayStation 3: benefits and challenges.

Rehabilitation interventions for the hand have shown benefits for children with Hemiplegia due to cerebral palsy or traumatic brain injury. Longer interventions are facilitated if training is provided in the patient's home, due to easier access to care and reduced impact on school or work activities. Providing remote rehabilitation over lengthy periods of time has however its own challenges. This paper presents two pediatric patients with hemiplegia, who practiced virtual hand rehabilitation games using a modified PlayStation 3 and 5DT sensing gloves. Despite severe initial hand spasticity, and occasional technology shortcomings, the subjects practiced for about 14 months, and 6 months, respectively. Game performance data for the second patient is presented. Follow-up evaluations 14 months from the removal of the PlayStation 3 from the home of the child with cerebral palsy showed that the patient had good retention in terms of grasp strength, hand function and bone health. Challenges of long-term home tele-rehabilitation are also discussed.

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).

Feasibility of modified remotely monitored in-home gaming technology for improving hand function in adolescents with cerebral palsy.

The convergence of game technology, the Internet, and rehabilitation science forms the second-generation virtual rehabilitation framework. This paper presents the first pilot study designed to look at the feasibility of at-home use of gaming technology adapted to address hand impairments in adolescents with hemiplegia due to perinatal stroke or intraventricular hemorrhage. Three participants trained at home for approximately 30 min/day, several days a week, for six to ten months. During therapy, they wore a fifths dimension technologies ultra sensing glove and played custom-developed Java 3D games on a modified PlayStation 3. The games were designed to accommodate the participants' limited range of motion, and to improve finger range and speed of motion. Trials took place in Indiana, while monitoFring/data storage took place at Rutgers Tele-Rehabilitation Institute (New Jersey). Significant improvements in finger range of motion (as measured by the sensing glove) were associated with self- and family-reported improvements in activities of daily living. In online subjective evaluations, participants indicated that they liked the system ease of use, clarity of instructions, and appropriate length of exercising. Other telerehabilitation studies are compared to this study and its technology challenges. Directions for future research are included.

In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic cerebral palsy.

UNLABELLED: Golomb MR, McDonald BC, Warden SJ, Yonkman J, Saykin AJ, Shirley B, Huber M, Rabin B, AbdelBaky M, Nwosu ME, Barkat-Masih M, Burdea GC. In-home virtual reality videogame telerehabilitation in adolescents with hemiplegic cerebral palsy. OBJECTIVE: To investigate whether in-home remotely monitored virtual reality videogame-based telerehabilitation in adolescents with hemiplegic cerebral palsy can improve hand function and forearm bone health, and demonstrate alterations in motor circuitry activation. DESIGN: A 3-month proof-of-concept pilot study. SETTING: Virtual reality videogame-based rehabilitation systems were installed in the homes of 3 participants and networked via secure Internet connections to the collaborating engineering school and children's hospital. PARTICIPANTS: Adolescents (N=3) with severe hemiplegic cerebral palsy. INTERVENTION: Participants were asked to exercise the plegic hand 30 minutes a day, 5 days a week using a sensor glove fitted to the plegic hand and attached to a remotely monitored videogame console installed in their home. Games were custom developed, focused on finger movement, and included a screen avatar of the hand. MAIN OUTCOME MEASURES: Standardized occupational therapy assessments, remote assessment of finger range of motion (ROM) based on sensor glove readings, assessment of plegic forearm bone health with dual-energy x-ray absorptiometry (DXA) and peripheral quantitative computed tomography (pQCT), and functional magnetic resonance imaging (fMRI) of hand grip task. RESULTS: All 3 adolescents showed improved function of the plegic hand on occupational therapy testing, including increased ability to lift objects, and improved finger ROM based on remote measurements. The 2 adolescents who were most compliant showed improvements in radial bone mineral content and area in the plegic arm. For all 3 adolescents, fMRI during grip task contrasting the plegic and nonplegic hand showed expanded spatial extent of activation at posttreatment relative to baseline in brain motor circuitry (eg, primary motor cortex and cerebellum). CONCLUSIONS: Use of remotely monitored virtual reality videogame telerehabilitation appears to produce improved hand function and forearm bone health (as measured by DXA and pQCT) in adolescents with chronic disability who practice regularly. Improved hand function appears to be reflected in functional brain changes.

Technical and patient performance using a virtual reality-integrated telerehabilitation system: preliminary finding.

Telerehabilitation is the provision of rehabilitation services at a distance by a therapist at a remote location. Integration with virtual reality (VR) is a relatively new addition to this field. This paper describes the technical and patient performance of a telerehabilitation application the remote console (ReCon) that is integrated with a VR system. The VR system consists of the Rutgers Ankle prototype robot, a local PC which is connected with a remote PC connected over the Internet. Six individuals in the chronic phase poststroke participated in a four week training program. They used the robot to interact with two VR simulations, while the therapist was in the same room during the first three weeks or in another room during the fourth week. Technical and patient performance was assessed in the transition from the third to the fourth week of training. Technical performance of the system was assessed based on bandwidth and lag of message transmission, which were found to be suitable for clinic-to-clinic communication. Patient performance (in terms of accuracy of ankle movement, exercise duration and training efficiency, mechanical power of the ankle, and number of repetitions) did not decrease during telerehabilitation in the fourth week. These preliminary findings over a short telerehabilitation intervention support the feasibility of remote monitoring of VR-based telerehabilitation without adverse effects on patient performance.

Telerehabilitation using the Rutgers Master II glove following carpal tunnel release surgery: proof-of-concept.

Carpal tunnel syndrome is caused by the compression of the median nerve as it transits the carpal tunnel, with an incidence of about 1% of the population. If surgery is needed, the treatment involves decompression of the median nerve followed sometimes by musculoskeletal outpatient rehabilitation. This paper presents a proof-of-concept pilot clinical trial in which the Rutgers Masters II haptic glove was tested on five subjects, who were two weeks post-hand surgery. Subjects trained for 13 sessions, 30 min per session, three sessions per week, and had no conventional outpatient therapy. Computerized measures of performance showed group effects in hand mechanical energy (1200% for the virtual ball squeezing and DigiKey exercises and 600% for the power putty exercise). Improvement in their hand function was also observed (a 38% reduction in virtual pegboard errors, and 70% fewer virtual hand ball errors). Clinical strength measures showed increases in grip (by up to 150%) and key pinch (up to 46%) strength in three of the subjects, while two subjects had decreased strength following the study. However, all five subjects improved in their tip pinch strength of their affected hand (between 20%-267%). When asked whether they would recommend the virtual reality exercises to others, four subjects very strongly agreed and one strongly agreed that they would.

Sensorimotor training in a virtual reality environment: does it improve functional recovery poststroke?

OBJECTIVE: To investigate the effectiveness of computerized virtual reality (VR) training of the hemiparetic hand of patients poststroke using a system that provides repetitive motor reeducation and skill reacquisition. METHODS: Eight subjects in the chronic phase poststroke participated in a 3-week program using their hemiparetic hand in a series of interactive computer games for 13 days of training, weekend breaks, and pretests and posttests. Each subject trained for about 2 to 2.5 h per day. Outcome measures consisted of changes in the computerized measures of thumb and finger range of motion, thumb and finger velocity, fractionation (the ability to move fingers independently), thumb and finger strength, the Jebsen Test of Hand Function, and a Kinematic reach to grasp test. RESULTS: Subjects as a group improved in fractionation of the fingers, thumb and finger range of motion, and thumb and finger speed, retaining those gains at the 1-week retention test. Transfer of these improvements was demonstrated through changes in the Jebsen Test of Hand Function and a decrease after the therapy in the overall time from hand peak velocity to the moment when an object was lifted from the table. CONCLUSIONS: It is difficult in current service delivery models to provide the intensity of practice that appears to be needed to effect neural reorganization and functional changes poststroke. Computerized exercise systems may be a way to maximize both the patients' and the clinicians' time. The data in this study add support to the proposal to explore novel technologies for incorporation into current practice.