Comparing integrated training of the hand and arm with isolated training of the same effectors in persons with stroke using haptically rendered virtual environments, a randomized clinical trial

Abstract

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.

Figures

Figure 1

CONSORT diagram. Describes participant flow through screening, randomization, data collection and intervention.

Figure 2

Virtual piano trainer. A: NJIT TrackGlove system, with the subject’s hand in the foreground and a screenshot of the Virtual Piano Trainer simulation in the background. B: Data for a single repetition of the Virtual Piano Trainer Simulation performed on Training Day 1 and another repetition on Training Day 8 performed by a representative subject. The horizontally hatched area represents the change in cued finger flexion secondary to training. Cued finger flexion angle increased slightly (top pair of lines). Non-cued finger flexion decreases more extensively (bottom set of lines) secondary to training, with the cross hatched area between the two lines indicating improved ability for finger individuation. C: Daily averages for finger fractionation score for HAS group subjects (open circles) and HAT group subjects (solid circles) during Virtual Piano Trainer simulation performance. Error bars represent the standard error of the mean. Please see text for further explanation of findings.

Figure 3

Hammer Task Simulation. A: NJIT RAVR System in foreground and a screenshot of the Hammer Task simulation in the background. B-D: Daily averages for Time to Task Completion (B), Trajectory Smoothness (C) and End Point Deviation (D) for HAS group subjects (open circles) and HAT group subjects (solid circles) during Hammer Task simulation performance. Lower smoothness scores indicate better performance. Error bars represent the standard error of the mean. Please see text for further explanation of findings.

Figure 4

Training simulations.