1. Introduction

Stroke is a leading cause of morbidity and the main cause of sensory-motor impairment worldwide. Several studies have reported that more than 65% of chronic stroke patients have had motor and sensory problems in the hemiparetic upper extremity [1,2]. Hand function is required for many activities of daily living (ADL), such as manipulating objects, eating, and computer and telephone use. Loss of hand function is a serious, common result of a cortical lesion from a cerebrovascular attack [3]. Therefore, recovery of hand function is of primary importance in the neurorehabilitation of stroke survivors. Furthermore, timing must be considered when planning neurorehabilitation focused on neuroplasticity following a stroke [4]. Previous studies have demonstrated that earlier rehabilitation leads to greater neuroplasticity in cortical areas controlling hand function in the lesioned hemispheres [5,6].

Previous evidence suggests that intensive repeated training is likely to be necessary to modify neural organization and promote recovery of hand motor skills in stroke patients [7,8]. Conventional rehabilitation for hand function and neuroplasticity, such as constraint-induced movement therapy [9], high-intensity training, and repetitive task-oriented training [10] often has unsatisfactory results due to insufficient patient motivation. In this regard, game-based virtual reality (VR) training is becoming a promising technology to promote motor recovery by providing high-intensity and repeated task-oriented rehabilitation with three-dimensional game programs involving patient body movement [11,12,13,14]. A 2017 Cochrane Review suggested that addition of VR to conventional care produced a significant difference between intervention and control groups in upper limb function [15]. A recent meta-analysis of 17 studies confirmed the feasibility of VR in early stroke rehabilitation and also suggested that VR intervention showed similar outcomes in upper extremity and ADL function to dose-matched conventional therapy [16].

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Additionally, robotic rehabilitation was posited to have a positive effect on attention; reduce the effort needed to enhance motor control, specifically in the hand; boost motivation; boost adherence to treatment; and boost sensorimotor integration [17]. Consequently, robotic rehabilitation may complement standard rehabilitation for restoring hand function [18]. However, despite these advantages, common problems with robotic devices are their high cost, large size, and rigid components. Most devices are designed for hospital use and are too complex for patients to use on their own at home. A sensor-based, soft, smart glove device can allow multiple degrees of freedom and complex motions with soft components [19,20,21]. There are several smart gloves with varying features from exoskeletal gloves to fabric or strip type gloves [22]. Commercial smart gloves have been used in many fields including motion capture, video games, industrial training, and medicine. In this study, we used the RAPAEL® Smart Glove digital system with game-based VR developed by Neofect (Yong-in, Republic of Korea) for task-oriented hand training with interactive motion recognition of user movement. A task-specific, interactive, game-based VR system combined with a soft smart glove can be used for motor recovery in stroke patients [21]. The RAPAEL® Smart Glove digital system with game-based VR system for post stroke patients showed that the smart glove group had greater improvement in upper extremity motor functions than did a conventional occupational therapy group [21,23]. Similar results were demonstrated in a study with cerebral palsy patients [24]. These studies reported consistent results for effectiveness of smart glove systems for upper extremity rehabilitation. However, no study examined cortical biosignals induced by the intervention. The most reliable and repeatable cortical hemodynamic response following motor stimulation consists of increase in oxygenated hemoglobin (OxyHb) coupled with a decrease in deoxygenated hemoglobin (deOxy Hb) [25]. Functional near-infrared spectroscopy (fNIRS) is a useful and non-invasive tool for measuring blood hemodynamic changes by recording the density of cerebral blood oxygenation in real-time [26]. fNIRS is more convenient, less expensive, and more tolerant of patient movement compared to functional magnetic resonance imaging (fMRI) and is more resistant to artifacts than electroencephalography (EEG) [26,27]. Although more evidence is required on the reliability and repeatability of fNIRS data, previous studies suggested fNIRS for localizing cortical activity by measuring hemodynamic changes [25,28].

The aim of this study was to examine the superiority of RAPAEL® Smart Glove digital training compared with conventional occupational therapy (OT) alone on upper extremity function in subacute stroke patients and cortical hemodynamic changes in a small sub-sample of patients.

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