Background
Hand impairment is a common condition that contributes substantially to disability in the U.S. and around the world [1]. In the case of stroke alone, it is estimated that approximately 80% of the 700,000 individuals who survive a stroke each year require hand therapy [2-4]. Other conditions that have a high incidence of hand impairment are hand and wrist trauma, high-level spinal cord injury, multiple sclerosis, traumatic brain injury, muscular dystrophies, and cerebral palsy. In all of these conditions the human motor system retains substantial capacity for plasticity, and thus intensive rehabilitation exercise reduces long-term hand impairment [5-7]. Unfortunately, there currently exist few validated technologies for at-home upper-extremity rehabilitation after a stroke. A recent systematic review of home-based upper extremity therapy analyzed only four studies, and only two of these included a self-guided intervention [8].
Therapy is limited because on-going rehabilitation exercise delivered one-on-one with a rehabilitation therapist is expensive. Gyms do not have appropriate equipment to facilitate practice of the fine motor skills needed to improve hand dexterity. Few devices are commercially available for at-home hand therapy and these are either expensive or not motivating. For example the HandMentor [9] and HandTutor [10] cost several thousand dollars, and the Amadeo (TyroMotion) is even more expensive. Virtual reality and computer gaming is promising for home-based rehabilitation because it can provide ecologically valid, intensive task specific training [11]. Systematic reviews of virtual-reality based rehabilitation delivered in the clinic indicate that is effective for arm rehabilitation, but there are fewer trials on hand rehabilitation [11,12]. Following written sheets of exercise prescribed by the therapist is therefore a fairly common low cost approach to hand therapy, but this approach often lacks in intensity, repetition, and motivational value—factors thought to be important for maximizing hand movement recovery [4-7,13]. Without guidance and a motivating rehabilitation regimen, individuals cease practice of their affected hand and do not recover to their full potential [2,3,14,15].
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Participating in music is a promising avenue for therapy because it is motivating, challenging, sensory-rich, and repetitive [16]. Further, participating in music after a stroke can induce plastic changes in the motor cortex as well as increase attention span, neuropsychological scores, cognitive functioning and well-being [17-24]. fMRI studies show that motor and auditory temporal processing are coupled during the act of listening, meaning the motor system is responsive to the auditory system [25-27].
Recognizing the potential benefits that music therapy provides, several devices for music-based therapy have been developed to focus on movement repetition and auditory feedback [16,20]. Adamovich developed a virtual piano trainer to retrain finger dexterity after stroke using a haptic device (CyberGrasp) worn over a dataglove (CyberGlove) [28]. Alten Muller and Schneider developed a customized electronic keyboard and drum pad designed to train gross and fine hand movement [16]. Although these devices promote movement using music, they are not focused on training hand movements used in activities of daily living such as key-pinch grip and pincer grasp. Based on the specificity of learning hypothesis in motor behavior, which holds that motor learning is most effective when practice sessions include movement conditions that closely resemble those required during performance of the task [29-31], training functional movements may be more beneficial to regaining motor function.
Objectively measuring hand use during therapy can be beneficial in providing effective rehabilitation. Quantitative feedback about movement performance can improve recovery of motor function in people with stroke [32]. It also enables users to track improvements in hand use, and provides an objective, unbiased, account of a patient’s movement practice.
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We developed the MusicGlove, a music-based rehabilitation device to help people regain hand function both in the clinic and at home [33,34] (Figure 1). It is an instrumented glove that requires the user to practice functional gripping movements to play a customized version of an open-source music game called Frets on Fire (FOF) inspired by the third most popular video game franchise to date, Guitar Hero. When the user touches the thumb lead on one of the five electrical leads on the fingertips or lateral aspect of the index finger, the device sends a signal to the computer through the USB port using a custom-made controller (Figure 1, right). The leads are positioned so as to require functional grips such as pincer grip or key pinch grip. In the computer game, colored notes scroll down the screen on five distinct frets. When the notes reach the bottom of the screen, the user must touch one of the respective leads on the glove with her thumb within a specifiable time window (Figure 1, left). Hitting the note causes it to explode, and increases the music volume, while missing the note decreases the volume. Correct notes are logged and displayed in a summary at the end of the game, providing a quantitative assessment of hand motor performance, including which grip the user is best at completing and how accurately the user completes each target gripping movement in the desired time window (e.g. late or early).
We previously conducted a usability study at the University of California, Irvine with 10 participants with chronic stroke. We found that the MusicGlove can be donned and used by people with severe hand impairment quantified by a Box and Block score of 7 (this test measures the number of blocks that subjects transport in a minute and a normal score is about 60) [33]. Further, the MusicGlove-based assessments of hand function were correlated with standard clinical evaluations (i.e. Box and Block score), suggesting the device provides self-measurable, quantitative feedback to users, clinicians, and caregivers relevant to rehabilitation progress. We also found that the addition of music to hand movement practice in a single training session significantly improved both objective measures of hand motor performance during training and self-ratings of motivation for training. In a questionnaire, the majority of participants stated that the device was a motivating tool for therapy, and that they would like to continue using it for rehabilitation.
The first aim of this pilot study was to test whether training with the MusicGlove would improve hand motor function. We hypothesized that following multiple training sessions, the MusicGlove would significantly improve hand motor control in people with a chronic stroke when compared to conventional tabletop exercises. In this study, we also used the MusicGlove to study the role of proprioceptive input in facilitating hand motor recovery. The second aim was that the more propriocpetively-rich movement training associated with the MusicGlove would produce larger improvements in hand motor control, compared to a matched form of isometric movement training, in which the fingers statically gripped a stationary object (the IsoTrainer, Figure 2, middle) and played the same music-based game. An implicit rationale that has been used to support the development and application of robotics technology for movement rehabilitation is that assisting individuals in completing movement will enhance somatosensory input, facilitating sensory motor recovery through Hebbian-like mechanisms [35,36]. Although the MusicGlove is not robotic, use of it generates proprioceptive input associated with the dynamic finger movement it requires, as well as the making and breaking of finger-to-thumb contacts. A third aim was to study how game score performance correlated with the primary outcome measure, the Box and Block score, since an important issue in rehabilitation science and practice is to improve objectivity, sensitivity, and ease of measurement of upper extremity outcomes.
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