Posts Tagged Hand
Published on May 8, 2019
NEOFECT has redesigned its Smart Board for Home in reply to feedback from patients recovering from stroke and other musculoskeletal conditions and neurological disorders.
The new Smart Board for Home NextGen includes a smaller surface to help patients use it at home more easily, a redesigned handle to better stabilize the user’s hand and arm, and updated gamified software.
The board size has been reduced from 42 inches to 32 inches so it can fit on most tables. To accommodate the weakened grip of many stroke patients, the redesigned handle includes more straps to better stabilize the user’s arm, ensure appropriate measurement for the post-game metrics, and provide a more secure, comfortable experience, according to the company in a media release.
“We took patient feedback and completely revamped the Smart Board for Home NextGen,” says Scott Kim, co-founder and CEO of San Francisco-based NEOFECT USA.
“This new model still has all the fun, measurable qualities patients can use at home, but now we’ve reduced even more barriers so that people of all abilities can gain back function in their hands and upper arms.”
Patients play games on the Smart Board for Home NextGen by placing their forearm in a cradle and moving their arm across the board. All movements are virtually mimicked on a Bluetooth-connected screen in real time. The gamified software also features an updated AI-powered algorithm to curate a more customized experience for each patient.
The Smart Board for Home NextGen games mimic real-world motions to rehabilitate users’ upper arms and shoulders, including new games like “Air Hawk” and “Tennis.”
Additionally, NEOFECT is developing a dual-player game for patients to use at home, which will be available in summer 2019.
[Source(s): NEOFECT, Business Wire]
[Abstract] Stroke, hand rehabilitation, motor synergy pattern correction, deep relaxation, multisensory stimulation, motor synergy rehabilitation.
Background: This study aims to determine motor synergy rehabilitation for upper limb functional recovery in stroke patients.
Methodology: A 48year old male, apparently normal till June, 2016, had an acute onset of right sided hemiparesis and slurred speech. 2 years later he reported with inability to use the upper limb and difficulty in walking independently. He was a diagnosed case of left capsule-ganglionic bleed with accelerated hypertension. His participation limitations were inability to finger feed, drink his coffee, dress and groom selfand discontinuation of his job as an automobile salesman. He received motor synergy rehabilitation for 6 weeks.
Result: At 6 weeks patient was able to perform scapular elevation and shoulder scaption up to 100° with isolated elbow and forearm movements. He re-learnt to release objects with wrist in neutral position with verbal cues. His ability to feel rough textures improved by 50% and silky texture by 40% (self-reported) throughout the limb except hand. He retrained to eat hard cut fruit, sip water from a glass with straw and comb hair with 20–25% assistance and rejoined his job once a week.
Conclusion: Muscle synergy rehabilitation can help to improve the functional use of upper limb in stroke.
[BLOG POST] Stroke rehabilitation: maximizing arm and hand function after stroke – Evidently Cochrane
Stroke is the leading cause of disability in developed countries. The effects of stroke on the upper extremities are a major cause of functional impairment. This impairment of the upper extremity often leads to loss of independence with activities of daily living and of important occupations. There has been much research along different schools of thought that are intended to help people regain function and range of motion in their hand and arm after stroke. A quick search through the Cochrane Library would lead you to over a dozen Systematic Reviews of different interventions for the upper limb for people with stroke: these include: Constraint-induced movement therapy, Mental practice, Mirror therapy, Virtual reality, Repetitive task practice, Electrical stimulation, and Occupational therapy for stroke … the list goes on.
So while it’s great that we are accumulating more and more evidence all the time, the challenge for therapists is that we just don’t have the time to spend scouring through the research, trying to find which one of these interventions is most effective for regaining upper limb function. Thankfully, Pollock and colleagues did the work for us and published a Cochrane Corner Overview paper titled “Interventions for Improving Upper Limb Function after Stroke.”
What was different about this study?
First, this study was called an “Overview” because it is basically a systematic review of systematic reviews of stroke on the upper extremity. In total, it included 40 systematic reviews (19 Cochrane Reviews and 21 non-Cochrane reviews with 18,078 participants) looking at improving arm function after stroke. That is a lot of research by any means. Their intent was to summarize the best evidence and, whenever possible, provide a side by-side comparison of interventions to give healthcare providers a succinct overview of the typical interventions for stroke to rehabilitate the upper limb.
So what did they find?
Good news and bad news. The bad news is they found that:
- “There is no high quality evidence for any interventions that are currently routine practice, and evidence is insufficient to enable comparison of the relative effectiveness of interventions.” In other words, the evidence is insufficient to show which of the interventions are the most effective for improving upper limb function.
The good news is that they did find:
- “Moderate quality evidence suggests that each of the following interventions may be effective: Constraint-Induced Movement Therapy (CIMT), Mental Practice, Mirror Therapy, interventions for sensory impairment, Virtual Reality and a relatively high dose of Repetitive Task Practice.”
- Moderate quality evidence also indicates that unilateral arm training (exercise for the affected arm) may be more effective than bilateral arm training (doing the same exercise with both arms at the same time).
- Some evidence shows that a greater dose of an intervention is better than a lesser dose.
- “Effective collaboration is urgently needed to support definitive randomized controlled trials of interventions used routinely within clinical practice. Evidence related to dose is particularly needed because this has widespread clinical and research implications.”
What do we know about how intense therapy should be?
Until recently, the Scottish Intercollegiate Guidelines Network 2010 (SIGN) guideline on stroke management and rehabilitation recommended considering Constraint Induced Movement. However, Repetitive Task Training was not routinely recommended for improving upper limb function, and increased intensity of therapy for improving upper limb function in stroke patients was also not recommended.
The NICE Guidelines Stroke Rehabilitation in Adults 2013 in the UK recommended that therapists consider Constraint Induced Movement Therapy, and offer initially at least 45 minutes of each relevant stroke rehabilitation therapy for a minimum of 5 days per week to people who have the ability to participate.
A recent article in Advances in Clinical Neuroscience and Rehabilitation, called The Future of Stroke Rehabilitation: Upper Limb Recovery, points out that there is real concern that the dose and intensity of upper limb rehabilitation after stroke is just too low. The article brings some research results that at least two to three hours of arm training a day, for six weeks, reduced impairment and improved function by clinically meaningful amounts when started one to two months after stroke. However, anything less than this does not appear to provide much benefit overall.
The newly released AHA/ASA Guidelines for Stroke 2016 pulls all the updated evidence together, and states that when it comes to upper limb therapy following stroke, the research suggests that a higher dose is better. These new guidelines state that the patients who perform more than three hours of therapy daily made significantly more functional gains than those receiving less than three hours. The AHA/ASA Guidelines states that there is preliminary evidence suggesting the ideal setting appears to be the inpatient rehabilitation setting. Additionally, rehabilitation is best performed by an interprofessional team that can include a physician with expertise in rehabilitation, nurses, physical therapists, occupational therapists, speech/language therapists, psychologists, and orthotists.
What are the implications for therapists?
In order to truly have evidence based practice, we first need to identify the highest quality evidence. One of the main goals of the Cochrane Overview was to direct therapists to the highest quality evidence when making day-to-day clinical decisions. As we know, each person and each stroke is different. So for therapists, this overview suggests that that we can and should look closely into the evidence for and consider using Constraint-Induced Movement Therapy (CIMT), Mental Practice, Mirror Therapy, Interventions for Sensory Impairment, Virtual Reality and Repetitive Task Training in our practice. Preliminary evidence also suggests that we need to provide at least three hours of therapy a day in the post-acute setting.
While updated guidelines and reviews of the best available evidence are very helpful, we must always use our clinical reasoning and judgement to decide which intervention is most appropriate in our particular practice setting. The guidelines suggest that it benefits the patients when we work synergistically to facilitate an increased intensity of therapy by combining our efforts within the interprofessional team. Finally, to be truly effective we should strive to translate the evidence into functional interventions to ultimately make meaningful improvements in everyday lives of our patients.
Stroke rehabilitation: maximizing arm and hand function after stroke by Danny Minkow is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License.
Based on a work at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010820.pub2/full. Images have been purchased for Evidently Cochrane from istock.comand may not be reproduced.
Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Cochrane Overview: interventions for improving upper limb function after stroke. Stroke 2015;46:e57-8. doi:10.1161/STROKEAHA.114.008295. Available from: http://stroke.ahajournals.org/content/46/3/e57.full.pdf+html
Pollock A, Farmer SE, Brady MC, Langhorne P, Mead GE, Mehrholz J, van Wijck F. Interventions for improving upper limb function after stroke. Cochrane Database of Systematic Reviews 2014, Issue 11. Art. No.: CD010820. DOI: 10.1002/14651858.CD010820.pub2.
Scottish Intercollegiate Guidelines Network (SIGN). Management of patients with stroke: rehabilitation, prevention and management of complications, and discharge planning. Edinburgh: SIGN; 2010. (SIGN publication no. 118). [cited June 2010]. Available from: http://www.sign.ac.uk/pdf/sign118.pdf
The Stroke Association. “Web Upper Limb Video. UK Stroke Forum: Cochrane overview of interventions to improve upper limb function after stroke”. YouTube videocast, 24:28. YouTube, 18 December, 2015. Web. 9 May 2016. https://www.youtube.com/watch?v=7XuSLrB319Q.
National Clinical Guideline Centre; National Institute for Health and Care Excellence (commissioner). Stroke rehabilitation: long term rehabilitation after stroke. London: National Clinical Guideline Centre, Royal College of Physicians; 2013 (NICE CG162). [Issued June 2013]. Available from: https://www.nice.org.uk/guidance/cg162
Ward NS, Kelly K, Brander F. The future of stroke rehabilitation: upper limb recovery. Advances in Clinical Neuroscience & Rehabilitation2015; 15(4): 6-8. Available from: http://www.acnr.co.uk/2015/09/the-future-of-stroke-rehabilitation-upper-limb-recovery/.
Clarke D, Forster A, Drummond A, Tyson S, Rodgers H, Jones F, Harris R. Delivering optimum intensity of rehabilitation in hospital and at home: what do we know? [PowerPoint slides]. Oral presentation at Key Advances in Stroke Rehabilitation conference, London, 12thJune 2013. Available from: http://www.medineo.org
Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2016;47(6):e98-e169. doi: 10.1161/STR.0000000000000098. Available from: http://stroke.ahajournals.org/content/47/6/e98.full.pdf+html
[ARTICLE] Changes in actual arm-hand use in stroke patients during and after clinical rehabilitation involving a well-defined arm-hand rehabilitation program: A prospective cohort study – Full Text
Improvement of arm-hand function and arm-hand skill performance in stroke patients is reported by many authors. However, therapy content often is poorly described, data on actual arm-hand use are scarce, and, as follow-up time often is very short, little information on patients’ mid- and long-term progression is available. Also, outcome data mainly stem from either a general patient group, unstratified for the severity of arm-hand impairment, or a very specific patient group.
To investigate to what extent the rate of improvement or deterioration of actual arm-hand use differs between stroke patients with either a severely, moderately or mildly affected arm-hand, during and after rehabilitation involving a well-defined rehabilitation program.
Design: single–armed prospective cohort study. Outcome measure: affected arm-hand use during daily tasks (accelerometry), expressed as ‘Intensity-of arm-hand-use’ and ‘Duration-of-arm-hand-use’ during waking hours. Measurement dates: at admission, clinical discharge and 3, 6, 9, and 12 months post-discharge. Statistics: Two-way repeated measures ANOVAs.
Seventy-six patients (63 males); mean age: 57.6 years (sd:10.6); post-stroke time: 29.8 days (sd:20.1) participated. Between baseline and 1-year follow-up, Intensity-of-arm-hand-use on the affected side increased by 51%, 114% and 14% (p < .000) in the mildly, moderately and severely affected patients, respectively. Similarly, Duration-of-arm-hand-use increased by 26%, 220% and 161% (p < .000). Regarding bimanual arm-hand use: Intensity-of-arm-hand-use increased by 44%, 74% and 30% (p < .000), whereas Duration-of-arm-hand-use increased by 10%, 22% and 16% (p < .000).
Stroke survivors with a severely, moderately or mildly affected arm-hand showed different, though (clinically) important, improvements in actual arm-hand use during the rehabilitation phase. Intensity-of-arm-hand-use and Duration-of-arm-hand-use significantly improved in both unimanual and bimanual tasks/skills. These improvements were maintained until at least 1 year post-discharge.
After stroke, the majority of stroke survivors experiences significant arm-hand impairments [1, 2] and a decreased use of the paretic arm and hand in daily life . The actual use of the affected hand in daily life performance depends on the severity of the arm-hand impairment [4–6] and is associated with perceived limitations in participation [7, 8]. Severity of arm-hand impairment is also associated with a decrease of health-related quality of life , restricted social participation , and subjective well-being [11, 12].
Numerous interventions and arm-hand rehabilitation programs have been developed in order to resolve arm-hand impairments in stroke patients [6, 13]. In the Netherlands, a number of stroke units in rehabilitation centres implemented a well-described ‘therapy-as-usual’ arm-hand rehabilitation program, called CARAS (acronym for: Concise Arm and hand Rehabilitation Approach in Stroke), serving a broad spectrum of stroke patients across the full stroke severity range of arm-hand impairments. The arm-hand rehabilitation program has been developed to guide clinicians in systematically designing arm-hand rehabilitation, tailored towards the individual patient’s characteristics while keeping control over the overall heterogeneity of this population typically seen in stroke rehabilitation centres. A vast majority of stroke patients who participated in CARAS improved on arm-hand function (AHF), on arm-hand skilled performance (AHSP) capacity and on (self-) perceived performance, both during and after clinical rehabilitation . The term ‘arm-hand function’ (AHF) refers to the International Classification of Functioning (ICF)  ‘body function and structures level’. The term ‘arm-hand skilled performance’ (AHSP) refers to the ICF ‘activity level’, covering capacity as well as both perceived performance and actual arm-hand use .
Improved AHF and/or AHSP capacity do not automatically lead to an increase in actual arm-hand use and do not guarantee an increase of performing functional activities in daily life [18–20]. Improvements at function level, i.e. regaining selectivity, (grip) strength and/or grip performance, do not automatically lead to improvements experienced in real life task performance of persons in the post-stroke phase who live at home [18, 21]. Next to outcome measures regarding AHF, AHSP capacity and (self-) perceived AHSP, which are typically measured in controlled conditions, objective assessment of functional activity and actual arm-hand use outside the testing situation is warranted [22, 23].
Accelerometry can be used to reliably and objectively assess actual arm-hand use during daily task performance [24–32]and has been used in several studies to detect arm-hand movements and evaluate arm-hand use in the post-stroke phase [20, 33–35]. Previous studies have demonstrated that, in stroke patients, movement counts, as measured with accelerometers, are associated with the use of the affected arm-hand (Motor Activity Log score) [36, 37] and, at function level, with the Fugl-Meyer Assessment . Next to quantifying paretic arm-hand use, accelerometers have also been used to provide feedback to further enhance the use of the affected hand in home-based situations . Most studies consist of relatively small [27, 30, 40–44] and highly selected study populations  with short time intervals between baseline and follow-up measurements. As to our knowledge, only a few studies monitored arm-hand use in stroke patients for a longer period, i.e. between time of discharge to a home situation or till 6 to 12 months after stroke [19, 44, 46]. However, they used a relatively small study sample and their intervention aimed at arm-hand rehabilitation was undefined. Both studies of Connell et al. and Uswatte et al. describe a well-defined arm hand intervention where accelerometry data were used as an outcome measure [27, 47]. However, the study population described by Connell et al. consisted of a relative small and a relative mildly impaired group of chronic stroke survivors. The study population described by Uswatte et al. consisted of a large group of sub-acute stroke patients within strict inclusion criteria ranges , who, due to significant spontaneous neurologic recovery within this sub-acute phase, had a mildly impaired arm and hand [48, 49]. This means that the group lacked persons with a moderately to severely affected arm-hand, who are commonly treated in the daily rehabilitation setting.
The course of AHF and AHSP of a broad range of sub-acute stroke patients during and after rehabilitation involving a well-defined arm-hand rehabilitation program (i.e. CARAS)  has been reported by Franck et al. . The present paper provides data concerning actual arm-hand use in the same study population, and focuses on two objectives. The first aim is to investigate changes in actual arm-hand use across time, i.e. during and after clinical rehabilitation, within a stroke patient group typically seen in daily medical rehabilitation practice, i.e. covering a broad spectrum of arm-hand problem severity levels, who followed a well-described arm-hand treatment regime. The second aim is to investigate to what extent improvement (or deterioration) regarding the use of the affected arm-hand in daily life situations differs between patient categories, i.e. patients with either a severely, moderately or mildly impaired arm-hand, during and after their rehabilitation, involving a well-defined arm-hand rehabilitation program.[…]
The recovery of hand function is one of the most challenging topics in stroke rehabilitation. Although the robot-assisted therapy has got some good results in the latest decades, the development of hand rehabilitation robotics is left behind. Existing reviews of hand rehabilitation robotics focus either on the mechanical design on designers’ view or on the training paradigms on the clinicians’ view, while these two parts are interconnected and both important for designers and clinicians. In this review, we explore the current literature surrounding hand rehabilitation robots, to help designers make better choices among varied components and thus promoting the application of hand rehabilitation robots. An overview of hand rehabilitation robotics is provided in this paper firstly, to give a general view of the relationship between subjects, rehabilitation theories, hand rehabilitation robots, and its evaluation. Secondly, the state of the art hand rehabilitation robotics is introduced in detail according to the classification of the hardware system and the training paradigm. As a result, the discussion gives available arguments behind the classification and comprehensive overview of hand rehabilitation robotics.
Stroke, caused by death of brain cells as a result of blockage of a blood vessel supplying the brain (ischemic stroke) or bleeding into or around the brain (hemorrhagic stroke), is a serious medical emergency . Stroke can result in death or substantial neural damage and is a principal contributor to long-term disabilities [1, 2]. According to the World Health Organization estimates, 15 million people suffer stroke worldwide each year . Although technology advances in health care, the incidence of stroke is expected to rise over the next decades . The expense on both caring and rehabilitation is enormous which reaches $34 billion per year in the US . More than half of stroke survivors experience some level of lasting hemiparesis or hemiplegia resulting from the damage to neural tissues. These patients are not able to perform daily activities independently and thus have to rely on human assistance for basic activities of daily living (ADL) like feeding, self-care, and mobility .
The human hands are very complex and versatile. Researches show that the relationship between the distal upper limb (i.e., hand) function and the ability to perform ADL is stronger than the other limbs [7–9]. The deficit in hand function would seriously impact the quality of patients’ life, which means more demand is needed on the hand motor recovery. However, although most patients get reasonable motor recovery of proximal upper extremity according to relevant research findings, recovery at distal upper extremity has been limited due to low effectivity . There are two main reasons for challenges facing the recovery of the hand. First, in movement, the hand has more than 20 degree of freedom (DOF) which makes it flexible, thus being difficult for therapist or training devices to meet the needs of satiety and varied movements . Second, in function, the area of cortex in correspondence with the hand is much larger than the other motor cortex, which means a considerable amount of flexibility in generating a variety of hand postures and in the control of the individual joints of the hand. However, to date, most researches have focused on the contrary, lacking of individuation in finger movements [12, 13]. Better rehabilitation therapies are desperately needed.
Robot-assisted therapy for poststroke rehabilitation is a new kind of physical therapy, through which patients practice their paretic limb by resorting to or resisting the force offered by the robots . For example, the MIT-Manus robot uses the massed training approach by practicing reaching movements to train the upper limbs ; the Mirror Image Movement Enabler (MIME) uses the bilateral training approach to train the paretic limb while reducing abnormal synergies . Robot-assisted therapy has been greatly developed over the past three decades with the advances in robotic technology such as the exoskeleton and bioengineering, which has become a significant supplement to traditional physical therapy [17, 18]. For example, compared with the therapist exhausted in training patients with manual labor, the hand exoskeleton designed by Wege et al. can move the fingers of patients dexterously and repeatedly [19, 20]. Besides, some robots can also be controlled by a patient’s own intention extracted from biosignals such as electromyography (EMG) and electroencephalograph (EEG) signals [21, 22]. These make it possible to form a closed-loop rehabilitation system with the robotic technology, which cannot be achieved by any conventional rehabilitation therapy .
Existing reviews of hand rehabilitation robotics on poststroke motor recovery are insufficient, for most studies research on the application of robot-assisted therapy on other limbs instead of the hand . Furthermore, current reviews focus on either the hardware design of the robots or the application of specific training paradigms [23, 24], while both of them are indispensable to an efficient hand rehabilitation robot. The hardware system makes the foundation of the robots’ function, while the training paradigm serves as the real functional parts in the motor recovery that decides the effect of rehabilitation training. These two parts are closely related to each other.
This paper focuses on the application of robot-assisted therapy on hand rehabilitation, giving an overview of hand rehabilitation robotics from the hardware systems to the training paradigms in current designs, for a comprehensive understanding is pretty meaningful to the development of an effective rehabilitation robotic system. The second section provides a general view of the robots in the entire rehabilitation robotic system. Then, the third section sums up and classifies hardware systems and the training paradigms in several crucial aspects on the author’s view. Last, the state of the art hand rehabilitation robotics is discussed and possible direction of future robotics in hand rehabilitation is predicted.[…]
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[Abstract] Soft Robotic Glove for Post-Stroke/Cerebral Palsy Hand Rehabilitation – Poster Presentation
Objective: The upper extremity plays a vital role in manipulation, communication and overall quality of life. Upper limb hemiplegia is one the most common presentations of stroke and cerebral palsy. Stroke is projected to increase dramatically as the over 65 population increases. Cerebral palsy (CP) is a non-progressive brain injury that occurs during the pre, peri, and post-natal periods of life, with an incidence ranging from 2-4 per 1000 live births. The purpose of this study is to evaluate the rehabilitative capacity of a pneumatically actuated soft and rigid hybrid actuator hand exoskeleton system called the REHAB Glove. Testing has been performed for post-stroke hand complications and a smaller pediatric version is also currently being tested to determine functional outcomes in cerebral palsy cases.
Research Question: Does the Soft Robotic Glove for post-stroke hand rehabilitation meet the basic standards for rehabilitation, can it be used on a pediatric scale for Cerebral Palsy patients and is it practical for patient use in an in-home setting?
Methods: Prior to glove use subject demographics were collected and subjects were prepped with instructions and safety. Post-stroke Subjects were timed and assessed for ease of donning the glove and then participated in continuous passive motion (CPM) of the hand using the glove. Post glove assessments consisting of hand evaluation and survey for ease of use were then collected. CP subjects are being tested in a similar fashion.
Results: From observation of 2 post-stroke patients, it has been noted that their hands can be very difficult to manipulate. This has complicated the process donning the glove to begin therapy. Detaching the finger portions of the glove from the pneumonic actuator device has been shown to simplify this process. The time elapsed to complete this process prior to modification was much greater, approximately a 608 sec. Also, redness has been noted in both stroke patients and 1 control subject for the CP study.
Conclusion: More modifications are necessary to simplify the process of gloving the hand and further testing and evaluation is necessary prior to establishing definitive results. Alterations in areas of increased pressure on the skin should also be considered to reduce redness.
The main goal of this project is to refine and optimize elements of the virtual reality-based training paradigms to enhance neuroplasticity and maximize recovery of function in the hemiplegic hand of patients who had a stroke.
PIs, Sergei Adamovich, Alma Merians, Eugene Tunik, A.M. Barrett
This application seeks funding to continue our on-going investigation into the effects of intensive, high dosage task and impairment based training of the hemiparetic hand, using haptic robots integrated with complex gaming and virtual reality simulations. A growing body of work suggests that there is a time-limited period of post-ischemic heightened neuronal plasticity during which intensive training may optimally affect the recovery of gross motor skills, indicating that the timing of rehabilitation is as important as the dosing. However, recent literature indicates a controversy regarding both the value of intensive, high dosage as well as the optimal timing for therapy in the first two months after stroke. Our study is designed to empirically investigate this controversy. Furthermore, current service delivery models in the United States limit treatment time and length of hospital stay during this period. In order to facilitate timely discharge from the acute care hospital or the acute rehabilitation setting, the initial priority for rehabilitation is independence in transfers and ambulation. This has negatively impacted the provision of intensive hand and upper extremity therapy during this period of heightened neuroplasticity. It is evident that providing additional, intensive therapy during the acute rehabilitation stay is more complicated to implement and difficult for patients to tolerate, than initiating it in the outpatient 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 specifically designed to deliver hand training when motion and strength are limited. The system uses adaptive algorithms to drive individual finger movement, gain adaptation and workspace modification to increase finger range of motion, and haptic and visual feedback from mirrored movements to reinforce motor networks in the lesioned hemisphere. We will translate the extensive experience gained in our previous studies on patients in the chronic phase, to investigate the effects of this type of intervention on recovery and function of the hand, when the training is initiated within early period of heightened plasticity. We will integrate the behavioral, the kinematic/kinetic and neurophysiological aspects of recovery to determine: 1) whether early intensive training focusing on the hand will result in a more functional hemiparetic arm; (2) whether it is necessary to initiate intensive hand therapy during the very early inpatient rehabilitation phase or will comparable outcomes be achieved if the therapy is initiated right after discharge, in the outpatient period; and 3) whether the effect of the early intervention observed at 6 months post stroke can be predicted by the cortical reorganization evaluated immediately after the therapy. 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 relatively little is known about the effect of very intensive, progressive VR/robotics training in the acute early period (5-30 days) 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.