HandTutor Enhanced Hand Rehabilitation after Stroke — A Pilot Study

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Summary of the paper “HandTutor Enhanced Hand Rehabilitation after Stroke — A Pilot Study” published in the journal Physiotherapy Research International

Objective 

The study assessed the potential therapeutic benefit of using HandTutor (sensorized glove with therapeutic software) in combination with traditional rehabilitation in a post-stroke sub-acute population. The study compares an experimental group receiving traditional therapy combined with HandTutor treatment, against a control group receiving only traditional therapy

The HandTutor System 

HandTutor consists of an ergonomic glove whose sensors allow the patient’s finger/s and wrist movements to be monitored on a computer screen and of specialized software (Figure 1).

Figure 1: Τhe HandTutor system consists of a glove that records kinematic motion parameters of the fingers and the wrist and specialized software with evaluation tests and therapeutic exercises in the form of serious computer games.

The software contains impairment-oriented training exercises based on repetitive and intensive active flexion and extension movements of the finger/s and the wrist. Based on the biofeedback concept, the HandTutor system provides exercise tasks on the computer screen that encourage the patients to flex and extend their finger/s and/or wrist, while the software provides the patient with impairment-oriented, augmented feedback. Moreover, the software incorporates evaluation tests with which various kinematic measurements can be recorded, such as active and passive range of motion, speed and frequency of movement, etc.

Method

Study Design

An assessor-blinded, randomized controlled pilot trial was conducted in the Reuth rehabilitation unit in Israel. Thirty-one stroke patients (age 65 ± 7 years old) in the sub-acute phase (10-70 days after stroke), were randomly assigned to one of the two groups (experimental or control).

The experimental group (n = 16) underwent a hand rehabilitation program using the HandTutor combined with traditional therapy for 20-30 minutes in 15 sessions for 3 weeks (5 sessions/week). The HandTutor treatment involved the performance of the task “Track a Target” in which the patients control the position of a ball on the computer screen with their fingers movements so that it is always within a moving track.  The patients performed the task for 1 minute followed by 1 minute breaks. The control group (n = 15) received only traditional therapy. The treatment programs for both groups were of similar duration and frequency.  

Evaluation Tests

All participants of both groups were evaluated at 4 time stages. These were: Τ1 (start of study), Τ2 (on the 10th day), Τ3 (on the 21st day when the intervention was stopped) και Τ4 (10 days after the end of intervention). Improvements were evaluated using three indicators:

1)    The Fugl-Meyer (FM) test,

2)    The Box and Blocks (B&B) test and

3)    Improvement parameters as determined by the HandTutor task “Track a Target”, such as speed of track and width of track.

Results

The average difference between Τ3 and Τ1 of the intervention group in comparison with the control group was statistically significantly a) higher for Box and Block (p=0.015), b) higher in the Fugl-Meyer scale (p=0.041) c) higher regarding the track speed (p<0.001) and d) lower regarding the track width (p<0.001).

Discussion  

The study showed that the combination of HandTutor with traditional hand rehabilitation programs is more effective than traditional hand rehabilitation alone. The HandTutor concept works on repetitive finger/s and wrist movements with kinematics augmented feedback. In addition, the HandTutorTM can work on isolated finger/wrist movements by targeting the kinematics impairments of ROM, speed, accuracy, and homogeneity of finger/s and wrist movement. Nevertheless, HandTutor can offer an integrated therapeutic approach by providing a complete suite of computer games that can be targeted at both motion and cognitive disorders.

If the patient to be treated has an impairment in proprioception, then in the initial stages of HandTutor treatment, the track width is set to a wide track and track scroll speed is set to a low setting. The software encourages the patients to move their fingers or wrist in order to stay within the track and patients are provided with feedback on their ability to perform the task. The HandTutor software therefore provides kinematics augmented feedback in the form of Knowledge of Results (KR) and Knowledge of Performance (KP). KR refers to the outcome and KP gives the patient an instruction on what to do to achieve an improved outcome. In this direction, the fact that the ball stays or not within the track, and the trajectory of the ball within the track provides KR, whereas the shape of the track provides KP. As the patient’s proprioception improves, the accuracy of their finger/s and wrist movement will also improve. This allows the therapist to increase the speed of the track scroll, and decrease the track width.

The augmented feedback provided to the patient and the therapist through the HandTutor software is quantitative and objective and consists of concurrent and/or terminal quantitative kinematics feedback, for example, speed of finger movement. The feedback is simple and easily understood by both the therapist and the patient.

Study limitations included small subject numbers, relatively short follow-up periods and minimal outcome measures. In addition, patients in the traditional therapy group were treated by only two therapists working at the same institute. Traditional therapy treatments vary from clinic to clinic. The results are therefore hard to monitor and to follow for specific changes or improvements.

 

Conclusions

The presented results suggest that the HandTutorTM may improve the function of grasping when combined with traditional hand exercises in a sub-acute post-stroke population. The results also suggest that HandTutor training should be further investigated as an adjunct to functional training in patients with hand motor dysfunction who are in the sub acute stage following stroke.

In order to support the hypothesis that the functional improvement measured in this study carries over to additional everyday objects and tasks, follow-up studies should incorporate additional reach, grasp, grip and release ADL tests. In addition, larger subject numbers and an extended follow-up period should be considered. Further studies are also needed to assess the efficacy of HandTutor treatment in the chronic phase of stroke hand rehabilitation.

More information can be found in the full paper, entitled: “HandTutorTM enhanced hand rehabilitation after stroke — a pilot study”, written by Carmeli, E., Peleg, S., Bartur, G., Elbo, E. and Vatine, J.-J, published in Physiotherapy Research International, n/a. doi: 10.1002/pri.485, 2010.

References

Desrosiers J, Bravo G, Hébert R, Dutil E, Mercier L. Validation of the box and block test. Archives of Physical Medicine and Rehabilitation 1994; 75: 751–755.

Folstein MF, Folstein SE, McHugh PR. ‘Mini-mental state’. A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research 1975; 12 (3): 189–198.

Fugl-Meyer AR. Post-stroke hemiplegia assessment of physical properties. Scandinavian Journal of Rehabilitation Medicine 1980; 7: 85–93. 

  • HandTutor is manufactured by the Israel company MediTouch and is exclusively distributed in Greece by Ostracon (www.ostraconmed.com).  
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Vassilios Protopappas, PhD, R&D Director, Ostracon Ltd, 23is Oktovriou, 28, 41222 Larissa, tel.: +30-2410 285477, vprotopappas@ostraconmed.com Nikolas K. Malizos, MSc, Sales & Marketing Director, Ostracon Ltd, 23is Oktovriou, 28, 41222 Larissa, tel.: +30-2410 285477, nmalizos@ostraconmed.com
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