Posts Tagged Upper Extremity

[Abstract] DESC glove: Prototyping a novel wearable device for post-stroke hand rehabilitation


The human brain integrates tactile sensory information from the fingertips to efficiently manipulate objects. Sensory impairments due to neurological disorders, e.g. stroke, largely reduce hand dexterity and the ability to perform daily living activities. Several feedback augmentation techniques have been investigated for rehabilitative purposes with promising outcomes. However, they often require the use of unpractical, expensive, or complex devices. In this work we propose the delivery of vibrotactile feedback based on the Discrete Event-driven Sensory feedback Control (DESC) to promote motor learning in post stroke rehabilitation. For this purpose, we prototyped a novel wearable device, namely the DESC glove. It consisted of a soft glove instrumented with PolyVinylidene Fluoride (PVDF) sensors at the fingertips and eccentric-mass vibration actuators to be worn on the forearm. We proceeded with the characterization of the device, which resulted in promising outcomes. The DESC glove was tested with ten healthy participants subsequently in a pick and lift timed task. The effects of augmented vibrotactile feedback were assessed comparing it to a baseline, consisting of wearing the device unpowered. The results of this pilot study showed a decrease in the time necessary to perform the task, a reduction in the time delay from load force to grip force activation and a diminishing of the grip force applied on the object, which led to a lower breakage rate in the intervention condition. These promising outcomes encourage further experiments with stroke survivors to validate the effectiveness of the device to improve hand dexterity and promote stroke rehabilitation.

via DESC glove | TU Delft Repositories

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[Abstract] Evaluation of upper limb function with digitizing tablet-based tests: reliability and discriminative validity in healthy persons and patients with neurological disorders


To evaluate discriminative validity, relative reliability and absolute reliability of four tablet-based tests for the evaluation of upper limb motor function in healthy persons and patients with neurological disorders.


Cross-sectional study in 54 participants: 29 patients with upper limb movement impairment due to a neurological condition recruited from an inpatient rehabilitation centre and 25 healthy persons. Accuracy, speed and path length were analysed for four tablet-based tests: “Spiral drawings,” “Tapping,” “Follow the dot” and “Trace a star.” The area under the receiver operating characteristic curve (AUC) was used to evaluate discriminative validity. Relative reliability was analysed with the intra-class correlation coefficient (ICC), and absolute reliability by limits of agreement (LoA) and minimal detectable difference (MDD).


All four tests showed excellent discriminative validity for the parameter accuracy (AUC 0.93–0.98). Tapping was the best test for discriminating patients from healthy persons. Test-retest reliability was good for accuracy in all tests (ICC = 0.76–0.88), but poor to moderate for speed and path length (ICC = 0.20–0.69). The MDD varied between 14% and 38%. Performance on the four tablet-based tests was stable between sessions, indicating that there was no learning effect.


The parameter accuracy showed excellent discriminative validity and reliability in all four tablet-based tests. Discriminative validity was excellent for all three parameters in the Tapping test. In the other tasks speed showed good to poor reliability, while the reliability of path-length was poor in all tasks. Results were comparable for the dominant and non-dominant hand. Tablet-based tests have the advantage that patients can use them for self-monitoring of upper limb motor function.

  • Implications for rehabilitation

  • Four tablet-based tests for the assessment of upper limb motor function in patients with upper limb neurological dysfunction were evaluated: “Spiral drawings”, “Tapping”, “Follow the dot” and “Trace a star”. The parameter accuracy in these four tests had excellent discriminative validity and good reliability.

  • Patients can perform the tests independently at home for self-monitoring of progress. This may increase patients’ motivation to exercise at home.

  • The results can be sent to physicians, enabling the earlier detection of deterioration, which may require medical attention.

via Evaluation of upper limb function with digitizing tablet-based tests: reliability and discriminative validity in healthy persons and patients with neurological disorders: Disability and Rehabilitation: Vol 0, No 0

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[ARTICLE] The Effectiveness of Wearable Upper Limb Assistive Devices in Degenerative Neuromuscular Diseases: A Systematic Review and Meta-Analysis – Full Text


Background: This systematic review summarizes the current evidence about the effectiveness of wearable assistive technologies for upper limbs support during activities of daily living for individuals with neuromuscular diseases.

Methods: Fourteen studies have been included in the meta-analysis, involving 184 participants. All included studies compared patients ability to perform functional tasks with and without assistive devices.

Results: An overall effect size of 1.06 (95% CI = 0.76-1.36, p < 0.00001) was obtained, demonstrating that upper limbs assistive devices significantly improve the performance in activities of daily living in people with neuromuscular diseases. A significant interaction between studies evaluating functional improvement with externally-assessed outcome measures or self-perceived outcome measures has been detected. In particular, the effect size of the sub-group considering self-perceived scales was 1.38 (95% CI = 1.08-1.68), while the effect size of the other group was 0.77 (95% CI = 0.41-1.11), meaning that patients’ perceived functional gain is often higher than the functional gain detectable through clinical scales.

Conclusion: Overall, the quality of the evidence ranged from low to moderate, due to low number of studies and participants, limitations in the selection of participants and in the blindness of outcome assessors, and risk of publication bias.

Significance: A large magnitude effect and a clear dose-response gradient were found, therefore, a strong recommendation, in favor of the use of assistive devices could be suggested.


1. Introduction

1.1. Background

Severe muscular weakness and chronic disability caused by neuromuscular diseases (e.g., muscular dystrophy, spinal muscular atrophy, spinal cord injuries or stroke) or neurodegenerative diseases (i.e., multiple sclerosis, amyotrophic lateral sclerosis) lead to the unavoidable loss of the possibility to perform even simple actions, such as walking, eating, and changing limbs posture. Patients suffer the consequences in terms of independence, quality of life, and self-esteem, given their need to continuously rely on assistance from their caregivers. This is particularly true for upper limbs, where independence is not primarily linked to essential tasks (e.g., eating, drinking, get dressed), but to simple actions not necessary for survival, but which increase the quality of life (e.g., pull up the glasses, scratch, use the mouse, etc.). To independently regain a lost motor function might be therefore a special experience towards a more independent daily life. Technological advancements might be a way to compensate patients’ muscular weakness through the use of Assistive Devices (ADs), which empower the user in the execution of daily life activities, and which are designed to maintain or to improve the functional capabilities of individuals with disabilities. ADs for lower limbs, such as wheelchairs and electric wheelchairs, have been successfully developed and diffused to deal with the deambulation issue. On the other side, the support of upper limbs related activities is more challenging. However, with the increased life expectancy, upper extremities functions became more and more important to be supported. Non-ambulant patients with neuromuscular disorders identified arm functions as their highest priority, indicating repositioning at night, bring hands to mouth, shift while seated, using the wheelchair joystick and the keyboard of a computer, and personal hygiene as priority functions to be regained (Janssen et al., ). The currently existing assistive devices to support upper limbs functions can be categorized in (i) end-effector devices, and (ii) exoskeletons. As for end-effector devices, they present a single interaction point between the user and the AD, usually located at forearm or hand level. The main disadvantage of robotic manipulator devices is the impossibility to control upper limb joints directly: the change in position of the interaction point results in unexpected movements of shoulder and elbow joints. As for exoskeletons, they are external structures worn by the patient, with joints and links placed in correspondence of human joints and bones. Patients usually prefer exoskeleton solutions, given that these devices not only help to execute the desired task, but they increase the perception of a self-executed movement. In a study conducted by Rupal et al. () with 118 participants, 96.8% prefer to use an exoskeleton over other mobility aids, and 84.1% like the idea that exoskeletons should be made available in care homes (Rupal et al., ). In addition, from a survey conducted by the authors at Lignano Sabbiadoro (Italy) on June 2015, during the annual meeting of the UILDM Association (Italian Association of Muscular Dystrophy), 10 out of 15 interviewed patients affected by muscular dystrophy answered that they prefer exoskeleton solutions for possible upper limbs assistive devices. ADs driving technology can be either passive, working through pre-stored mechanical energy, or active, working with motors, and therefore able to exert greater forces or to control movements more precisely. However, even if a remarkable number of works have been published dealing with the development of innovative electromechanical technologies (e.g., Ragonesi et al., ; Jung et al., ; Dunning et al., ; Sin et al., ; Dalla Gasperina et al., ), scientific evidence for the benefits of these technologies is still lacking, which could justify costs and effort. When dealing with Assistive Devices, or in general with complex technologies, the demonstration of the effectiveness of their use is rather difficult to be demonstrated following the canonical research studies design [i.e., Randomized Control Trial (RCT) design], even if some effort in this direction is currently ongoing (Antonietti et al., ). This is due to several reasons, such as the difficulty to demonstrate the validity of the proposed approach independently from the users’ placebo effect (e.g., it is impossible to perform a blind session), the high cost of the technology and therefore the impossibility to recruit many volunteers contemporary, and the Ethical Committee procedures for non CE-marked devices. A recent systematic review on devices to assist and/or rehabilitate upper limbs made a quite large classification of different devices used, showing an intense research work towards the development of new technologies, which however are rarely methodologically properly tested, and therefore they have difficulties to effectively reach end-users (Onose et al., ). […]

Continue —-> The Effectiveness of Wearable Upper Limb Assistive Devices in Degenerative Neuromuscular Diseases: A Systematic Review and Meta-Analysis

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[Abstract + References] The effectiveness of extracorporeal shock wave therapy for improving upper limb spasticity and functionality in stroke patients: a systematic review and meta-analysis

To assess the effectiveness of Extracorporeal Shock Wave Therapy for reducing spasticity and improving functionality of the upper limb in stroke survivors.

A systematic review of MEDLINE, Cochrane Central Register of Controlled Trials, CINAHL, PEDro, REHABDATA, Scielo, Scopus, Web of Science, Tripdatabase and Epistemonikos from 1980 to April 2020 was carried out.

The bibliography was screened to identify randomized controlled clinical trials that applied extracorporeal shock waves to upper limb spastic muscles in post-stroke individuals. Two reviewers independently screened references, selected relevant studies, extracted data and assessed risk of bias using the PEDro scale. The primary outcome was spasticity and functionality of the upper limb.

A total of 1,103 studies were identified and 16 randomized controlled trials were finally included (764 individuals) were analyzed. A meta-analysis was performed and a beneficial effect on spasticity was found. The mean difference (MD) on the Modified Ashworth Scale for comparison extracorporeal shock wave versus sham was −0.28; with a 95% confidence interval (CI) from −0.54 to −0.03. The MD of the comparison of extracorporeal shock wave plus conventional physiotherapy versus conventional physiotherapy was −1.78; 95% CI from −2.02 to −1.53. The MD for upper limb motor-function using the Fugl Meyer Assessment was 0.94; 95% CI from 0.42 to 1.47 in the short term and 0.97; 95% CI from 0.19 to 1.74 in the medium term.

The extracorporeal shock wave therapy is effective for reducing upper limb spasticity. Adding it to conventional therapy provides an additional benefit.

via The effectiveness of extracorporeal shock wave therapy for improving upper limb spasticity and functionality in stroke patients: a systematic review and meta-analysis – Rosa Cabanas-Valdés, Pol Serra-Llobet, Pere Ramón Rodriguez-Rubio, Carlos López-de–Celis, Mercé Llauró-Fores, Jordi Calvo-Sanz, 2020

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[Abstract] A Wearable Hand Rehabilitation System with Soft Gloves


Hand paralysis is one of the most common complications in stroke patients, which severely impacts their daily lives. This paper presents a wearable hand rehabilitation system that supports both mirror therapy and task-oriented therapy. A pair of gloves, i.e., a sensory glove and a motor glove, was designed and fabricated with a soft, flexible material, providing greater comfort and safety than conventional rigid rehabilitation devices. The sensory glove worn on the non-affected hand, which contains the force and flex sensors, is used to measure the gripping force and bending angle of each finger joint for motion detection. The motor glove, driven by micromotors, provides the affected hand with assisted driving-force to perform training tasks. Machine learning is employed to recognize the gestures from the sensory glove and to facilitate the rehabilitation tasks for the affected hand. The proposed system offers 16 kinds of finger gestures with an accuracy of 93.32%, allowing patients to conduct mirror therapy using fine-grained gestures for training a single finger and multiple fingers in coordination. A more sophisticated task-oriented rehabilitation with mirror therapy is also presented, which offers six types of training tasks with an average accuracy of 89.4% in real-time.

via A Wearable Hand Rehabilitation System with Soft Gloves – IEEE Journals & Magazine

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[Abstract] A Multisession Evaluation of a Collaborative Virtual Environment for Arm Rehabilitation


In recent years, several multi-user virtual environments (VEs) have been developed to promote motivation and exercise intensity in motor rehabilitation. While competitive VEs have been extensively evaluated, collaborative and competitive rehabilitation VEs have seen relatively little study. Therefore, this article presents an evaluation of a VE for post-stroke arm rehabilitation that mimics everyday kitchen tasks and can be used either solo or collaboratively. Twenty subacute stroke survivors exercised with the VE for four sessions, with the first and third sessions involving solo exercise and the other two involving collaborative exercise. Exercise intensity was measured using inertial sensors while motivation was measured with questionnaires. Results showed high motivation and exercise intensity over all four sessions, and 11 of 20 participants preferred collaborative over solo exercise while only 4 preferred solo exercise. However, there were no differences in motivation, exercise duration, or exercise intensity between solo and collaborative sessions. Thus, we cannot currently claim that collaborative exercises are beneficial for upper limb rehabilitation. Future studies should evaluate other collaborative VE designs in different settings (e.g., at home) and with different participant pairs (e.g., patient-unimpaired) to find effective ways to utilize collaborative exercises in motor rehabilitation.

via A Multisession Evaluation of a Collaborative Virtual Environment for Arm Rehabilitation | PRESENCE: Virtual and Augmented Reality | MIT Press Journals

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[BLOG POST] Hand Rehab after Stroke: The Top 5 Evidenced-Based Methods

After a stroke, it’s challenging enough to navigate the medical system to find what services you need, let alone the right treatment approach for you.

You’ve probably heard a lot of recommendations on how to recover hand function after stroke, and everyone seems to give different advice. That’s why we sifted through the research for you. We’ll explain the top 5 evidence-based methods for hand rehabilitation, why they work, and who they work for.

The top 5 evidence-based treatments for improving hand function after stroke:

  1. Constraint‐induced movement therapy (CIMT)
  2. Mental practice
  3. Mirror therapy
  4. Virtual reality
  5. High dose repetitive task practice

Constraint-Induced Movement Therapy

Unaffected arm wearing oven mitt for at-home constraint therapy.
You can restrict your unaffected side at home by wearing an oven mitt or placing it inside your pants or sweatshirt pocket. This will help remind you to rely on your affected side when completing therapy tasks.

What it is:

Constraint-Induced Movement Therapy (CIMT) is a neuro-rehabilitation method where the non-affected hand is constrained or restricted in order to force the brain to use the affected hand, thereby increasing neuroplasticity.

There are two key components: constraint and shaping.

Constraint refers to the way in which the hand is restricted. Therapists have used casts, splints, and mitts to restrict the use of the non-affected hand. None of them have been shown to be more effective than the other.

Shaping involves repetitive movements or activities at the patient’s ability level which become progressively harder. Therapists use shaping techniques to avoid overwhelming the motor system.

Why it works:

Our brain automatically completes a task in the easiest way possible. Our brain is more interested in completing a task than in how it is accomplished.

After a stroke, it’s easier for our brain to do tasks one-handed. This leads to “learned non-use”.

When we constrain our non-affected hand, suddenly our stronger hand becomes the weaker, less functional hand and we’re forced to use our affected hand. Our affected hand might not have much movement, but to our brain any movement is better than no movement, and the brain is highly motivated to figure out how to accomplish a task.

This is where the “shaping” piece is so important. If you are presented with rehab tasks that overwhelm the motor system or are higher level than your affected hand can functionally do, you’ll be more likely to knock the table over than to participate in picking up pennies from the table.

If you knock the table over with your affected hand, your occupational therapist might actually be excited about it; but in practical life finding that balance of not being too easy and not being so hard that you give up is an important lesson for every human being, not just those after stroke.

Who it’s for:

This approach is used for people who have at least 10 degrees of active wrist and finger extension, as well as 10 degrees of thumb abduction (the ability of the thumb to move out of the palm).

It’s been shown to be effective even years after stroke. Lower intensity CIMT is better than higher intensity in the very early stages after stroke.

Mental Practice

Man in headphones listening to mental practice recordings.
You might listen to an audio recording describing the sequence of throwing a ball, imagining yourself doing it. After listening, actually practice throwing the ball the way you envisioned!

What it is:

Mental practice, sometimes called motor imagery or mental imagery, is a training method for improving your hand and arm function without moving a muscle!

Mental practice is typically done by listening to pre-recorded audio that describes in detail the motor movement of a specific task. The listener imagines their hand and arm moving in a “typical” way, and the instructor provides cues to extend their arm or open their fingers, as well as the entire sensory experience of the task.

While it’s true that you can do mental practice on its own, it’s best combined with physical practice immediately following.

Why it works:

Brain scans show that similar parts of the brain are activated whether movement is actual, observed or imagined.

It’s a separate area of the brain that’s responsible for actually triggering the muscle movement, but it goes to show that there’s a lot more required of the brain to complete a task than just sending a signal to the muscle.

Who it’s for:

Mental practice has been shown to improve arm movement and functional use in patients after stroke of all levels of abilities and as a treatment approach for people months or years after stroke!

Mirror Therapy

Unaffected hand and its mirror image reflected in mirror box.
It is critical to stay focused on the reflected image of your hand during mirror therapy, imagining that it is your affected side performing the target movements.

What it is:

Mirror therapy is another voodoo-seeming approach that has a lot of scientific evidence to back it up. It essentially tricks your brain into thinking your affected hand is moving.

You position a mirror to reflect your non-affected hand, while hiding your affected hand. Any movement of your non-affected hand will be reflected in the mirror and make it seem as though you are actually moving your affected hand.

Why it works:

The approach is centered around mirror neurons, which fire in your brain when you see your arm move. Typically, we think about motor neurons being sent from the brain to the muscle, but we don’t realize that mirror neurons are connected to the motor neurons.

After a stroke you lose the ability to access your motor neurons, but not your mirror neurons. By accessing your mirror neurons through seeing your movement (even if the movement is fake), you are tapping into the network between the neurons.

It’s like trying to reconnect with an old friend on Facebook by finding the friends they’re connected with. It might not be the most direct approach in a real life situation, but in stroke rehab that friend of a friend might be your strongest connection.

Who it’s for:

Mirror therapy can be used for people with no movement of the hand or smaller movements of the hand and shoulder, but not functional movement of the hand.

If you have functional movement of your hand, meaning individual finger movement and wrist movement, you have surpassed the benefit that mirror therapy can provide.

It can be used early after stroke, as well as in the chronic stages of stroke.

Virtual Reality

Neofect Smart Board virtual reality arm exercise system.
The Neofect Smart Board is a non-immersive virtual reality rehabilitation system.

What it is:

Virtual reality uses a computer interface to simulate a real life objects and events. It’s become an increasingly more prevalent rehabilitation technique to provide motivation and engagement in therapy.

There are two types:

  1. Immersive: goggles are placed over the eyes and the patient is visually in a different environment than their actual physical one
  2. Non-immersive: sensors are placed on the body and track the movement of the body and the movements are shown on a screen

Why it works:

Virtual reality works best when paired with traditional therapy. It’s theorized to provide more motivation and engagement for the intensity of therapeutic exercise needed for neuroplasticity. It’s been shown to beneficial in high doses, meaning more than 20 hours.

Another possible factor of why virtual reality works are the same mechanisms that make mirror therapy effective (tapping into the mirror neurons) could be similar.

Virtual reality also creates a biofeedback loop: your brain sends a signal to the muscle, the brain receives a signal back in the form of visual or auditory input. Basically, you get rewarded for your effort.

Who it’s for:

Virtual reality can be used with people who have mild to severe impairments, and from early after stroke to years out.

When deciding what’s right for you, it’s important to look at the adjustability of the device to meet you where you’re at and also to increase in difficulty as you improve.

If you have minimal movements, you’ll want a virtual reality tool specifically for stroke rehabilitation. If you have more movement, it’s possible to use gaming systems not specifically designed for rehab, but make sure you have the support to optimize it for rehab.

High Dose Repetitive Task Practice

Putting coins in a piggy bank during repetitive task practice.
There are many ways to do task-specific training at home. Placing coins into a piggy bank is just one of them!

What it is:

Repetitive Task Practice is when you practice a task or a part of a task over and over. Task-specific training is a type of repetitive task practice, and refers to the task we complete that is relevant to our daily life.

“Reach to grasp, transport and release” is a type of task-specific training because it is one of the common motor requirements for many functional daily tasks.

The keys for repetitive task practice:

  • Task must be meaningful
  • Participant must be an active problem-solver
  • Real life objects are used
  • Difficulty level is not too high and not too low
  • Repetition is key

Why it works:

Repetitive Task Practice is based on motor learning theory. Our brains are driven by function. We’re able to achieve neuroplasticity with development of skills, as our brain processes the demands of the task, which have motor and cognitive components.

It’s often used with other treatments, such as virtual reality, to increase the 15 hour dosage that has been shown to be beneficial.

Who it’s for:

Task-specific practice is generally used and is studied in people who have some functional ability of their hand. It’s been shown to be beneficial throughout the rehabilitation process.

Even though the research has been focused on “functional ability” of the hand by practicing reach, grasp, transport, release; there’s potential for recovery by using the same principles of task-specific practice: real life objects, functional tasks, and problem-solving even without the ability to grasp.

Functionally, we can use our affected upper extremity as a stabilizer, an assist, or for manipulation. There are lots of ways to get that side involved to prevent “learned non-use” and to improve your problem-solving skills.

Now what?

There are two key factors to any hand recovery method: support and meaning.

Neofect aims to support and inspire you to live your best life with virtual reality tools that can be used as part of a constraint-induced movement therapy program or with repetitive task practice.

Our comprehensive recovery and wellness app: Neofect Connect and our YouTube Channel: Find What Works are based on the principles of repetitive task practice and aim to give you the tools to live your best life.

Now the only question is, what are you waiting for?

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.

via Hand Rehab after Stroke: The Top 5 Evidenced-Based Methods

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[BLOG POST] Rehab with Real-World Objects for Improved Hand Use After Stroke

If you’ve been through stroke rehabilitation, chances are that you’re familiar with the phrase, “use it or lose it”. Your therapist likely told you this while explaining the principle of neuroplasticity, the brain’s potential to reorganize after damage to regain lost functions. Hopefully “use it or lose it” has helped you remember to engage your weaker arm throughout the day in order for it to make progress!

Here’s another catchy rehab phrase for your repertoire: “you gain what you train”. Research shows that practicing arm movements related to daily living goals may be more effective at improving arm function than standard, non-goal-directed arm exercise. Basically, if you want to be able to hold eating utensils or write with your affected arm, you’re better served by putting a fork or a pen to use than you are by lifting a dumbbell or pinching putty.

“You gain what you train” seems obvious, right? So, why belabor the point? Because many stroke survivors are not practicing real-world skills with their affected arm on their own time. Learning a new skill requires hours of practice and thousands of repetitions. Stroke survivors must ensure they are dedicating sufficient time at home to addressing their specific arm use goals in order to improve.

Think about your current post-stroke home exercise program. Does it go beyond basic stretching and strengthening? If not, consider incorporating task-specific training into your routine to maximize arm and hand function.


Task-specific training overview

What is task-specific training (TST)?

Task-specific training is a therapy technique focusing on improving function of a hemiplegic (weakened) arm through repeated activity practice. Just like how you learned to tie your shoes or ride a bike, TST requires consistent performance of the component steps of a task to help the brain re-learn the big-picture skill.

Task-specific training activities for the post-stroke hemiplegic arm incorporate a real-world object and involve the following four steps:

  • Reaching for the object
  • Grasping the object
  • Moving or manipulating the object
  • Releasing the object

Ideally, a participant will repeat this sequence many times over multiple sessions to show skill improvement. Research studies generally indicate that more repetitions and a greater frequency of training are better.

Who can do TST?

Stroke survivors with sufficient movement to repeatedly reach for an object, hold on to it, and release it using their affected arm are good candidates for TST.

Anyone with activity restrictions on their affected side, or those who experience pain when using their affected side should consult with their medical team before attempting TST.


How to do task-specific training at home:

First, think about what you would like to be able to do better using your affected arm and hand. Ideally, TST goal activities should be centered around a task that has clear and consistent steps and also involves an object. Although that might sound complicated, there are countless TST possibilities available in your home using your everyday belongings! Any of the following ideas make for great TST goals:

  • Using a cup, fork, or spoon
  • Brushing your hair
  • Pulling your pants up
  • Turning a book page
  • Opening a door handle
  • Writing your signature
  • Putting coins into a piggy bank
  • Hammering a nail
  • Putting laundry into a basket

TST skills can also involve your other hand. Consider using your affected hand in the dominant role of a two-handed task, while letting your stronger hand play the role of helper or stabilizer.

  • Fastening buttons or zippers
  • Tying shoelaces
  • Opening containers
  • Pouring liquid from one container into another
  • Putting credit cards into a wallet
  • Wringing out a wet washcloth
  • Putting a stamp on an envelope
  • Folding laundry into halves or quarters

Because TST involves repeating the steps of an activity using your affected arm, we need to think about how to measure performance. Completing a reach/grasp/manipulate/release sequence is considered one repetition of a task. The goal of TST is to complete as many repetitions as possible. View the examples of measuring one repetition from the TST tasks on our list above:

Note: The affected arm starts and ends in the same position relative to the task object/s (e.g. on the tabletop next to the object)
Using a spoon: Pick up the spoon from the tabletop, bring it up to your mouth, put it back on the tabletop, return hand to starting position
Writing your signature: Pick up the pen from the tabletop, bring it to paper to write your full name, put the pen back on the tabletop, return hand to starting position

Note: For a two-handed task, you may choose to repeatedly pick up the stabilized object using your unaffected hand, or hold it throughout the task
Putting credit cards into a wallet: One repetition = pick up credit card from tabletop, insert and remove credit card from wallet (held by unaffected hand), place credit card on tabletop, return hand to starting position

After you have defined your activity and what a repetition looks like, you’re ready to go. You may choose to practice one activity in a TST session, or, for a longer session, you may pick two or three goal areas.


How much and how often should I do TST?

Studies show that between one and five repetitions of a task per minute may be ideal to promote improved arm function. Gauge your performance by performing a 15-minute TST test. Have a helper time the number of repetitions you can do during this period. If you have achieved between 15 and 100 repetitions, you’re in the TST sweet spot: continue practicing the skill! If you are over 100 repetitions, it is time to make the task more difficult by add more complex elements (e.g. using heavier objects, attempting the task from standing as opposed to sitting). If that is not possible, try practicing a different, harder skill.

Research has also demonstrated that completing 60 minutes of task-specific training four times per week can produce significant arm function improvements. This is an amount that you may have to build up to. If one hour seems daunting, try to ease into TST practice by attempting increasingly longer intervals (e.g. aim for 5 more minutes of TST each time).

What if I can’t do task-specific training?

Survivors who have some but not all required arm functions to perform TST may choose to perform a modified version incorporating the elements within their capabilities. For instance, TST might consist of repeatedly reaching to tap an object with the hand as opposed to grasping and releasing it.

If you have minimal to no movement in your affected arm, you will not be able to perform TST. However, your affected side can and should still play a role in your daily living tasks. Use your stronger side to place your affected arm within your field of vision during tabletop tasks. If you are doing a two-handed task, use the stronger arm to place the weaker arm to hold or stabilize objects. Even though doing this is not TST, you are still promoting function of your affected side while preventing learned non-use.

Do I have to do task-specific training after stroke?

TST is just one tool in your upper extremity stroke rehab toolbox. There are several other evidence-supported activities that may improve arm and hand function. Some people may not be able to perform TST without the guidance of a therapist, while others may not be motivated by the intervention. If you have questions on how to perform TST at home or whether it is the right option for you, consult with your therapy team.


The bottom line: practice means progress

We’ll conclude with one final catchy rehab phrase: “practice means progress”. Needless to say, improving weakened arm function after a stroke can be a long and sometimes frustrating ordeal. However, additional keys to success are right in front of you in the forms of your daily tasks and personal belongings. With practice and repetition, your goals are within reach!


French B, Thomas LH, Coupe J, McMahon NE, Connell L, Harrison J, et al.. Repetitive task training for improving functional ability after stroke.Cochrane Database Syst Rev. 2016; 2016:CD006073. doi: 10.1002/14651858.CD006073.pub3.

Hatem SM, Saussez G, Della Faille M, et al. Rehabilitation of Motor Function after Stroke: A Multiple Systematic Review Focused on Techniques to Stimulate Upper Extremity Recovery. Front Hum Neurosci. 2016;10:442. Published 2016 Sep 13. doi:10.3389/fnhum.2016.00442

Lang, Catherine E. PT, PhD; MacDonald, Jillian R.; Gnip, Christopher DPT Counting Repetitions: An Observational Study of Outpatient Therapy for People with Hemiparesis Post-Stroke, Journal of Neurologic Physical Therapy: March 2007 – Volume 31 – Issue 1 – p 3-10 doi: 10.1097/01.NPT.0000260568.31746.34

Waddell, K. J., Strube, M. J., Bailey, R. R., Klaesner, J. W., Birkenmeier, R. L., Dromerick, A. W., & Lang, C. E. (2017). Does Task-Specific Training Improve Upper Limb Performance in Daily Life Poststroke? Neurorehabilitation and Neural Repair, 31(3), 290–300.

Waddell KJ, Birkenmeier RL, Moore JL, Hornby TG, Lang CE. Feasibility of high-repetition, task-specific training for individuals with upper-extremity paresis. Am J Occup Ther. 2014;68(4):444-453. doi:10.5014/ajot.2014.011619

via Rehab with Real-World Objects for Improved Hand Use After Stroke

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[ARTICLE] In-Home Rehabilitation Using a Smartphone App Coupled With 3D Printed Functional Objects: Single-Subject Design Study – Full Text


Background: Stroke is a major cause of long-term disability. While there is potential for improvements long after stroke onset, there is little to support functional recovery across the lifespan. mHealth solutions can help fill this gap. mRehab was designed to guide individuals with stroke through a home program and provide performance feedback.

Objective: To examine if individuals with chronic stroke can use mRehab at home to improve upper limb mobility. The secondary objective was to examine if changes in limb mobility transferred to standardized clinical assessments.

Methods: mRehab consists of a smartphone coupled with 3D printed household items: mug, bowl, key, and doorknob. The smartphone custom app guides task-oriented activities and measures both time to complete an activity and quality of movement (smoothness/accuracy). It also provides performance-based feedback to aid the user in self-monitoring their performance. Task-oriented activities were categorized as (1) object transportation, (2) prehensile grip with supination/pronation, (3) fractionated finger movement, and (4) walking with object. A total of 18 individuals with stroke enrolled in the single-subject experimental design study consisting of pretesting, a 6-week mRehab home program, and posttesting. Pre- and posttesting included both in-laboratory clinical assessments and in-home mRehab recorded samples of task performance. During the home program, mRehab recorded performance data. A System Usability Scale assessed user’s perception of mRehab.

Results: A total of 16 participants completed the study and their data are presented in the results. The average days of exercise for each mRehab activity ranged from 15.93 to 21.19 days. This level of adherence was sufficient for improvements in time (t15=2.555, P=.02) and smoothness (t15=3.483, P=.003) in object transportation. Clinical assessments indicated improvements in functional performance (t15=2.675, P=.02) and hand dexterity (t15=2.629, P=.02). Participant’s perception of mRehab was positive.

Conclusions: Despite heterogeneity in participants’ use of mRehab, there were improvements in upper limb mobility. Smartphone-based portable technology can support home rehabilitation programs in chronic conditions such as stroke. The ability to record performance data from home rehabilitation offers new insights into the impact of home programs on outcomes.



Stroke is a major cause of disability, leading to restriction of occupational performance for stroke survivors [1,2]. It is estimated that 30%-60% of stroke survivors continue to have residual limitations in upper extremity movements after traditional rehabilitation services [3]. At the end of rehabilitation services, survivors are commonly given a written home exercise program to guide recovery in chronic stages of stroke [4]. Shortcomings of the written home exercise program include complaints of being unengaging and patients not continuing the program [4]. Knowing that upper limb motor deficits can reduce quality of life [5], it is important to support survivors to recover as much function as possible. Upper limb recovery after stroke is identified as a research priority by survivors of stroke, caregivers, and health professionals [6].

Research demonstrates that individuals with chronic stroke are capable of making gains in performance with continued practice. The research so far has focused on interventions led by therapists [7,8]. It is improbable that direct oversight by a therapist is a feasible solution for long-term recovery. For chronic conditions such as stroke, better supporting the individual’s ability to self-manage their long-term recovery could offer a more sustainable approach. Use of mHealth (ie, mobile technology to manage health) offers the opportunity for individuals to engage in rehabilitative activities while monitoring their performance and managing their health behaviors [9,10]. mHealth apps can assist users in meeting basic needs, thereby giving a sense of autonomy and competence [11]. In addition, participants have reported that it is enjoyable to use apps [12]. Smart devices are equipped with interactive components (eg, sensors, cameras, speakers, and vibrators) capable of measuring human movement and providing feedback [13]. Readily available smartphone technology can be the basis of a home rehabilitation system.

There has been an increase in app development for stroke rehabilitation. A review of apps designed for stroke survivors or their caregivers found that 62% of apps addressed language or communication [14]. Other apps addressed stroke risk calculation, identifying acute stroke, atrial fibrillation, direction to emergency room or nearest certified stroke center, visual attention therapy, and a mere 4% addressed physical rehabilitation [14]. Importantly, apps for rehabilitation did not focus on upper limb function [14]. Use of technology to guide and measure performance in task-specific training of the upper extremity after stroke has primarily included clinical or laboratory-based interventions [15,16]. Task-specific programs are function based, with practice of tasks relevant to activities of daily life, and have been shown to be efficacious [17,18]. Use of instrumented objects in a laboratory setting has resulted in patients reporting they enjoyed the experience [15]. There has been less research on the use of portable technology for upper limb rehabilitation in a home setting for individuals with chronic arm/hand deficits after stroke.

Previous Work

mRehab (mobile Rehab) was created to better support in-home upper limb rehabilitation programs (Figure 1) [13]. It incorporates a task-oriented approach and immediate performance-based feedback. Exercise programs that include feedback have resulted in better outcomes compared with programs without feedback [19,20]. mRehab consists of 3D printed household objects (a mug, bowl, key, and doorknob) integrated with a smartphone and an app. The app guides participants through practice of activities of daily living, for example, sipping from a mug. It can also consistently measure time to complete an activity and quality of movement (smoothness/accuracy) during the performance of activities of daily living. The system is described in more detail in previous articles that have evaluated it in primarily laboratory-based settings [13,21].

Figure 1. In-home use of mRehab: (A) selecting an activity in mRehab; (B) turning key activity; and (C) vertical mug transfer activity.

There is little information on in-home use of technology for rehabilitation in chronic stroke. While technology-based systems designed for rehabilitation have been developed, they have typically been examined in laboratory or clinical settings [22,23]. The results of this study will provide much needed evidence of the ability of individuals with chronic stroke to use technology in a home-based program with oversight only upon request. This mimics clinical practice, in which patients are discharged from rehabilitation with a home program and then need to self-manage their recovery. We examine the individual’s adherence to exercise and if they required support with the technology. The impact of the home-based mRehab program on functional mobility was also examined. While individuals with chronic stroke were selected for the first examination of mRehab in a home-based setting, the system has the potential to be used by individuals that have arm/hand deficits due to other underlying pathology.[…]

Continue —-> JMU – In-Home Rehabilitation Using a Smartphone App Coupled With 3D Printed Functional Objects: Single-Subject Design Study | Langan | JMIR mHealth and uHealth

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[Abstract] Hyperbaric Oxygen and Focused Rehabilitation Program: A Feasibility Study in Improving Upper Limb Motor Function After Stroke


Neuroplasticity and recovery after stroke can be enhanced by a rehabilitation program pertinent to upper limb motor function exercise and mental imagery (EMI) as well as hyperbaric oxygen therapy (HBOT).

We assessed the feasibility and safety of the combined approach utilizing both HBOT and EMI, and derived preliminary estimates of its efficacy. In this randomized controlled trial, twenty-seven patients with upper extremity hemiparesis 3-48 months after stroke were randomized to receive either a complementary rehabilitation program HBOT-EMI (intervention group), or EMI alone (control group).

Feasibility and safety were assessed as total session attendance, duration of sessions, attrition rates, missing data, and intervention-related adverse events. Secondary clinical outcomes were assessed with both objective tools and self-reported measures at baseline, 8 weeks (end of treatment), and 12-weeks follow-up. Session attendance, duration and attrition rate did not differ between the groups; there were no serious adverse events.

Compared to baseline, there were significant sustained improvements of objective and subjective outcomes’ measures in the intervention group, and a single improvement in an objective measure in the control group. Between-group outcome comparisons were not statistically significant.

This study demonstrated that the combination HBOT-EMI was a safe and feasible approach in patients recovering from chronic stroke. There were also trends for improved motor function of the affected upper limb after the treatments.

Registration-URL: NCT02666469. NOVELTY: – HBOT combined with an upper limb exercise and mental imagery rehabilitation program is feasible and safe in chronic stroke patients. – This combined approach showed trends for improved functional recovery.

via Hyperbaric Oxygen and Focused Rehabilitation Program: A Feasibility Study in Improving Upper Limb Motor Function After Stroke. – Applied Physiology, Nutrition, and Metabolism

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