Optimizing Hand Rehabilitation Post-Stroke Using Interactive Virtual Environments

Project AbstractThis application seeks funding to continue our on-going investigation into the effects of intensive, high dosagetask and impairment based training of the hemiparetic hand, using haptic robots integrated with complexgaming and virtual reality simulations. A growing body of work suggests that there is a time-limited period ofpost-ischemic heightened neuronal plasticity during which intensive training may optimally affect the recoveryof gross motor skills, indicating that the timing of rehabilitation is as important as the dosing. However, recentliterature indicates a controversy regarding both the value of intensive, high dosage as well as the optimaltiming for therapy in the first two months after stroke. Our study is designed to empirically investigate thiscontroversy. Furthermore, current service delivery models in the United States limit treatment time and lengthof hospital stay during this period. In order to facilitate timely discharge from the acute care hospital or theacute rehabilitation setting, the initial priority for rehabilitation is independence in traNational Science Foundation ers and ambulation.This has negatively impacted the provision of intensive hand and upper extremity therapy during this period ofheightened neuroplasticity. It is evident that providing additional, intensive therapy during the acuterehabilitation stay is more complicated to implement and difficult for patients to tolerate, than initiating it in theoutpatient setting, immediately after discharge. Our pilot data show that we are able to integrate intensive,targeted hand therapy into the routine of an acute rehabilitation setting. Our system has been specificallydesigned to deliver hand training when motion and strength are limited. The system uses adaptive algorithmsto drive individual finger movement, gain adaptation and workspace modification to increase finger range ofmotion, and haptic and visual feedback from mirrored movements to reinforce motor networks in the lesionedhemisphere. We will translate the extensive experience gained in our previous studies on patients in thechronic phase, to investigate the effects of this type of intervention on recovery and function of the hand, whenthe training is initiated within early period of heightened plasticity. We will integrate the behavioral, thekinematic/kinetic and neurophysiological aspects of recovery to determine: 1) whether early intensive trainingfocusing on the hand will result in a more functional hemiparetic arm; (2) whether it is necessary to initiateintensive hand therapy during the very early inpatient rehabilitation phase or will comparable outcomes beachieved if the therapy is initiated right after discharge, in the outpatient period; and 3) whether the effect of theearly intervention observed at 6 months post stroke can be predicted by the cortical reorganization evaluatedimmediately after the therapy. This proposal will fill a critical gap in the literature and make a significantadvancement in the investigation of putative interventions for recovery of hand function in patients post-stroke.Currently relatively little is known about the effect of very intensive, progressive VR/robotics training in theacute early period (5-30 days) post-stroke. This proposal can move us past a critical barrier to the developmentof more effective approaches in stroke rehabilitation targeted at the hand and arm.