Funded by: National Institute on Disability, Independent Living and Rehabilitation Research (NIDILRR)

Grant: Rehabilitation Engineering Research Center, HHS90RE6021,  11/1/15 -10/30/20

Hand function is integral to all activities of daily living and fundamental to human independence. It is unimaginably difficult to pursue education, employment and community participation without being able to independently use one’s hands and arms.  Despite the critical importance of hand dexterity, few studies have addressed hand rehabilitation post stroke. To date, the best efforts of groups studying traditionally presented as well as technology-based therapeutic interventions for the hemiplegic hand and arm have produced measurable changes in motor function and motor control but fall far short of major reductions in disability.  The neuroscience and rehabilitation literature support the importance of providing high dosages of repetitive and progressing movements in order to drive neuroplasticity and motor recovery. However, current service delivery models in the United States limit treatment time and length of stay in acute care and rehabilitation hospitals post-stroke - negatively impacting the provision of high dosage hand and upper extremity therapy.  This problem speaks to the need to develop a home-based technological intervention to support high-dosage, on-going practice. Exciting new technologies have now made this approach possible.  It has been established that virtual reality facilitated training can provide this desirable dosage in terms of additional repetitions per training session. The primary aim of this proposal is to test an exciting new technology that can be easily used in the home for long-term hand and upper extremity training.  This system uses serious games - specifically developed for the hemiplegic hand - played using a passive forearm support that is integrated with the Leap Motion Device for hand tracking and real-time interaction with virtual environments. Importantly, this system is affordable and easy to use.  In addition to the practical problem of providing a low-cost method for on-going motor rehabilitation post-stroke, there is a scientific controversy regarding the optimal time frame, after the stroke event, in which one should initiate high dosage intensive practice.  Our second aim will test this controversy by evaluating the effectiveness of early (immediately after discharge), home-based virtually simulated hand/arm gaming activities compared to a delayed group (1 month post discharge). Our pilot data show that we are able to provide intensive, targeted hand therapy during the early period of recovery post-stroke. An important characteristic of our system is the ability of the gaming simulations to be changed during each training session based upon patient performance. The system uses adaptive algorithms to drive individual finger movement, gain adaptation to increase finger range of motion, and auditory and visual feedback to enhance motor learning. We have developed a library of 12 impairment and task-based simulations that train hand manipulation and arm transport. We will translate the extensive experience gained in our previous studies on patients in the chronic phase and those in the acute rehabilitation hospital to investigate the effects of this home-based intervention on recovery and function of the hand. We will integrate the behavioral, the kinematic/kinetic and neurophysiological aspects of recovery to determine: 1) whether high dosage, on-going home-based training focusing on the hand will result in a more functional hemiparetic arm and (2) whether initiating this high-dosage therapy during the early period of heightened plasticity post-stroke will achieve better outcomes when compared to a later initiation.  This proposal will fill a critical gap in the literature and make a significant advancement in the investigation of putative interventions for recovery of hand function in patients post-stroke. Currently there is little known about the effect of very intensive, progressive training in the early period post-stroke. This proposal can move us past a critical barrier to the development of more effective approaches in stroke rehabilitation targeted at the hand and arm.