This article has been accepted for publication in a future issue of this journal, but has not been
fully edited. Content may change prior to final publication. Citation information: DOI 10.1109/TNSRE.2015.2513675, IEEE
Transactions on Neural Systems and Rehabilitation Engineering
TNSRE-2015-00086.R2
Use of a Portable Assistive Glove to Facilitate
Rehabilitation in Stroke Survivors with Severe
Hand Impairment
Heidi C. Fischer, Kristen M. Triandafilou, Kelly O. Thielbar, Jos M. Ochoa, Emily C. Lazzaro,
Kathleen A. Pacholski, and Derek G. Kamper, Member, IEEE
Abstract Treatment options for stroke survivors with severe
hand impairment are limited. Active task practice can be
restricted by difficulty in voluntarily activating finger muscles
and interference from involuntary muscle excitation. We
developed a portable, actuated glove-orthosis, which could be
employed to address both issues. We hypothesized that
combining passive cyclical stretching (reducing motoneuronal
hyperexcitability) imposed by the device with active-assisted,
task-oriented training (rehabilitating muscle activation) would
improve upper extremity motor control and task performance
post-stroke. Thirteen participants who experienced a stroke 2-6
months prior to enrollment completed 15 treatment sessions over
5 weeks. Each session involved cyclically stretching the long
finger flexors (30-min) followed by active-assisted task-oriented
movement practice (60-min). Outcome measures were completed
at 6 intervals: three before and three after treatment initiation.
Overall improvement in post-training scores was observed across
all outcome measures, including the Graded Wolf Motor
Function Test, Action Research Arm Test, and grip and pinch
Manuscript received March 13, 2015; revised June 11, 2015; accepted
October 28, 2015. Date of publication ; date of current version .
The contents of this article were developed under a grant from the
Department of Education, National Institute on Disability and Rehabilitation
Research, (grant no. H133B080031). However, those contents do not
necessarily represent the policy of the Department of Education, and you
should not assume endorsement by the Federal Government.
H. C. Fisher, OTD was with the Sensory Motor Performance Program of
the Rehabilitation Institute of Chicago, Chicago, IL 60611 USA. She is now
with the Department of Occupational Therapy, University of Illinois at
Chicago, Chicago, IL 60612 USA (email: hwaldi1@uic.edu).
K. M. Triandafilou, M.S. is with the Sensory Motor Performance Program
of the Rehabilitation Institute of Chicago, Chicago, IL 60611 USA (email:
triandafilou@ricres.org).
K. O. Thielbar, M.S., OTR/L is with the Sensory Motor Performance
Program of the Rehabilitation Institute of Chicago, Chicago, IL 60611 USA
(email: kthielbar@ric.org).
J. M. Ochoa, M.S. is with the Sensory Motor Performance Program of the
Rehabilitation Institute of Chicago, Chicago, IL 60611 USA (email:
jmauro8a@gmail.com).
E.C. Lazzaro was with the Sensory Motor Performance Program of the
Rehabilitation Institute of Chicago, Chicago, IL 60611 USA (email:
elazzaro@ric.org).
K. A. Pacholski is with the Sensory Motor Performance Program of the
Rehabilitation Institute of Chicago, Chicago, IL 60611 USA (email:
kpacholski@ric.org).
D. G. Kamper, Ph.D. is with the Biomedical Engineering Department,
Illinois Insitute of Technology, Chicago, IL 60616 USA and the Sensory
Motor Performance Program of the Rehabilitation Institute of Chicago,
Chicago, IL 60611 USA (email: kamper@iit.edu).
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1
strength (p0.02), except finger extension force. No significant
change in spasticity was observed. Improvement in upper
extremity capabilities is achievable for stroke survivors even with
severe hand impairment through a novel intervention combining
passive cyclical stretching and active-assisted task practice, a
paradigm which could be readily incorporated into the clinic.
Index Termsfingers, hand, occupational therapy,
rehabilitation, stretch, stroke recovery
I. INTRODUCTION
F UNCTIONAL use of the upper extremity is fundamental
to performance of a variety of tasks important for self-
care, employment, and leisure activities. Unfortunately, stroke
often results in chronic hemiparesis involving the upper
extremity [1, 2], and the hand in particular [3, 4]. While
interventions such as constraint-induced movement therapy
have shown promise in facilitating rehabilitation after stroke
[5-7], individuals with severe hemiparesis are often excluded
from these clinical trials [8-10].
Stroke survivors with more limited motor capabilities can
be difficult to treat as they have multiple impairment
mechanisms. They are likely to be affected by motoneuronal
hyperexcitability, manifested as spasticity [11-13] excessive
coactivation [12, 14, 15], or prolonged muscle relaxation time
[16, 17]. Yet, they also exhibit profound weakness, resulting
from motoneuronal activation deficits [18] and a limited
ability to appropriately modulate activation patterns [19, 20].
Recently, we observed that even a single session of cyclic
stretching of the long finger flexors could lead to at least
transient improvement in motor control of the hand in stroke
survivors [21]. The stretching seemed to reduce flexor
hyperexcitability, as evidenced by reduction in relaxation
times [16, 21, 22]. Stretching on three consecutive days led to
beneficial carryover effects from one stretching session to the
next in stroke survivors in the subacute phase of recovery [23].
Additionally, we demonstrated that constant extension
assistance applied to the impaired hand could improve active
range of motion [24] and accuracy of finger movements [25]
in stroke survivors. Subjects were able to take advantage of
residual flexion strength in the digits to be able to flex the
digits against the constant extension assistance, while the
assistance allowed the subjects to reach functional areas of the
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Transactions on Neural Systems and Rehabilitation Engineering
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workspace [26]. This is akin to the increased arm workspace
which can be obtained by supporting the weight of the arm
[27]. Repetitive practice of movement to new areas of the
workspace would ideally lead to development of new
activation patterns and better modulation of existing patterns.
We developed an actuated glove orthosis, the eXtension
Glove (X-Glove), to provide both cyclical stretching of digit
muscles and assistance of digit extension. We employed this
device to test the efficacy of a novel rehabilitation paradigm
for stroke survivors in the subacute phase of recovery. During
each therapy session, passive cyclical stretching of the digits
was first applied by the X-Glove. Participants then performed
active movement therapy, assisted by the X-Glove. We
hypothesized that this combined treatment would result in
improved motor control of the upper extremity for subacute
stroke survivors with substantial upper extremity impairment.
II. METHODS
A. Device
While numerous devices have been developed to assist hand
rehabilitation [28-30], for a review of exoskeletons see [31],
the X-Glove is one of the few to independently actuate each
digit while also allowing free movement of each joint,
portability, and interaction with real objects. Cables serving as
external extensor tendons run through cable guides attached to
the dorsal side of a modified batting or driving glove (Fig. 1).
The guides form a bridge over each joint to allow joint flexion
but to prevent joint hyperextension. They were fabricated from
glass filled nylon using selective laser slintering (SLS) and
were sewn into each glove. For each digit, the single cable
from the corresponding actuator is split into three cables to
pass through the guides in order to provide greater lateral
stability. The linear servoactuators (L12, Firgelli
Technologies, Inc.) move the cable, thereby generating
extension torque at each joint in the digit. An in-line tension
sensor (Model 11, Honeywell Sensotec) resides between the
motor and the cable to measure the force in each cable. A
RabbitCore microcontroller (RCM 3410; Digi International,
Inc.) reads in force data and generates the appropriate Pulse
Width Modulation (PWM) signal for each motor. The linear
actuators are mounted to a carbon fiber wrist splint, which
maintains wrist posture in neutral flexion/extension and
ulnar/radial deviation. All of the support electronics reside in a
small box that can be strapped to the upper arm. The entire
device can be driven for ~10 hours from a 2-cell lithium ion
battery worn on the waist. The X-Glove operates in one of two
distinctive modes, as controlled by the push of a button. In the
stretching mode, the X-Glove imposes concurrent movement
of all 5 digits from a flexed posture to full extension with the
digits straight and aligned with the palm. A slow movement
(cable displacement of 4 mm/s or less) is imposed to preclude
any spastic response due to the stretching. The digits are held
in the extended posture for 1 s and returned to the flexed
posture. This cycle is repeated for as long as desired.
In the active training mode, the X-Glove provides constant
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2
Fig. 1. The X-Glove. Linear actuators provide extension forces according to
tension sensor measurements in order to help open the hand.
extension assistance, thereby helping the participant to
perform high intensity occupational therapy. A proportional-
integral-derivative (PID) closed-loop controller was
implemented in order for each linear motor to provide a
constant level of extension force (measured with the in-line
tension sensor), equal to the force required to keep the digit in
the extended neutral posture when the user is relaxed. Thus,
the user can actively close the hand at any time by creating
flexion force greater than the extension force produced by the
X-Glove. The device determines the required amount of
extension assistance automatically by periodically measuring
the force required to move the digits into full extension while
the user remains passive.
B. Participants
A convenience sample of 15 stroke survivors enrolled in a
pilot study to examine the efficacy of a novel therapy
paradigm utilizing the X-Glove. Participants were required to
be at least 40 years old and to have experienced a single stroke
2-6 months prior to enrollment in the study. We targeted
volunteers with substantial hand impairment, as classified as
Stage 3 or 4 on the Stage of Hand section of the Chedoke-
McMaster Stroke Assessment (CMSA-H) [32]. Potential
subjects were excluded if they received anti-spasticity
injections in the upper extremity prior to study initiation, had
greater than 20 of flexion contracture in any digit, were
unable to follow one step commands, or had significant upper
extremity pain (greater than 6/10 pain via self report).
Northwestern Universitys Institutional Review Board
(Chicago, IL) approved the study design and participants
signed informed consent before enrolling in the study.
C. Intervention
Each subject participated in up to three 90-minute sessions
per week, for a total of 15 training sessions. For the first 30
minutes of each session, the X-Glove cyclically stretched the
thumb and finger flexors while the participant remained
relaxed, as described previously [21-23]. Each cycle lasted
roughly 15 seconds, resulting in approximately 120 open/close
cycles throughout the 30-min stretching session.
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TABLE I
SUBJECT DEMOGRAPHICS
# of previous UE
Impaired Age Months Baseline Baseline
Gender Handedness intervention
side (years) Post CMSA-H FMUE
studies
XS01 F R R 53 5.1 0 3 19
XS02 M R R 43 5.5 0 3 14
XS03 M R R 53 5.8 0 3 9
XS04 M R R 55 5.3 0 3 12
XS05 F L R 51 2.0 1 3 17
XS06 F R L 59 3.6 2 3 25
XS07 M R L 58 2.8 1 3 19
XS08 M L L 75 3.9 0 3 17
XS09 M R R 74 4.7 0 3 23
XS10 M R L 84 2.3 0 3 20
XS11 M R L 78 3.6 0 4 17
XS12 M L L 65 3.5 1 3 11
XS13 M L R 71 4.1 0 3 8
3F/10M 9R/4L 7R/6L 63 12 4 1 30.3 165

CMSA-H: Chedoke McMaster Stroke Assessment Stage of Hand Score, UE: upper extremity, L: left, R: right, FMUE: Fugl-
Meyer Assessment for the upper extremity.

Immediately afterward, participants employed the X-Glove
for 60 minutes of active training guided by a research
occupational therapist using a task-oriented protocol. In this
therapy protocol (see Appendix), developed at the
Rehabilitation Institute of Chicago by Dr. Mary Ellen
Stoykov, participants were encouraged to perform high
repetitions of tasks, task components, and performance skills
focused mainly on the hand. As part of the protocol, the
Canadian Occupational Performance Measure (COPM) [33]
was administered to identify goals that incorporated use of the
affected hand. Part of each training session was used to
practice these tasks, while the remainder was used to practice
component skills. The occupational therapist provided
feedback to the client regarding performance and graded tasks
as well as the environment as needed to optimize challenge.
The therapist recorded total repetitions completed during each
session.
therapy (Post); and 1 month after completion of therapy
(Follow-up). As we were interested both in measures of task
performance with the upper extremity and in evaluations of
impairment, we used a set of outcome measures. Clinical task
performance was evaluated with the Action Research Arm
Test (ARAT) [34], the Graded Wolf Motor Function Test
(GWMFT) [35] and the Chedoke Arm and Hand Inventory
(CAHAI-9) [36]. Impairment was evaluated with the Fugl-
Meyer Assessment for Motor Recovery after Stroke for the
Upper Extremity (FMUE) [37] and hand strength assessments.
For the latter, the 3-point palmar (PPS) and lateral pinch
strengths (LPS) were measured with a pinch gauge (PG-60,
B&L Engineering), grip strength (GS) was quantified with a
dynamometer (JAMAR 5030J1 Hand Dynamometer), and
finger extension force (EXT) was recorded with a digital force
gauge (Mark-10 Corp. MG200).
Additional outcome measures were included to further
examine effects of the treatment. They consisted of the
Modified Modified Ashworth Scale (MMAS) [38, 39] and the
Motor Activity Log (MAL) [40]. The MAL was administered
once prior to treatment, immediately following treatment, and
one-month later. A single research therapist, uninvolved with
the participants training, completed all of the assessments for
each stroke survivor.

Fig. 2. Time course of the evaluations (indicated by arrows) and intervention

(gray shaded boxes). E. Data Analysis
In this preliminary study, subjects served as their own
D. Outcome Measures
control. For the first analysis, data from the three evaluations
Participants were evaluated 6 times (Fig. 2): three performed prior to initiation of treatment were averaged to
evaluations, each spaced one week apart, prior to the start of create the Pre values. Repeated-measures multivariate
training (Pre-1, 2, and 3); after the 9th training session (Mid); analysis of variance (rm-MANOVA) was performed using
immediately following the conclusion of the 6 weeks of

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SPSS software (IBM SPSS Advanced Statistics; IBM Corp) to
determine whether the combination of passive cyclical
stretching with active-assist therapy impacted the outcome
variables. Specifically, the impact of the within-subject factor
Evaluation (4 levels: Pre, Mid, Post, Follow-up) on the
outcome measures was examined. Post hoc univariate analyses
of variance (ANOVAs) were performed separately on each
dependent variable (outcome) for the independent factor found
to have a significant effect, as determined by a Wilks lambda
p-value<0.05. Post hoc pairwise comparisons with a
Bonferroni correction for multiple comparisons were
conducted to further evaluate the impact across the
evaluations.
As participants were in the subacute phase of recovery,
linear regression analyses were subsequently performed to
compare the rates of change of the outcome measures from
before treatment initiation to those during the treatment phase.
To be able to look across all subjects, the regression models
were fit to the change in outcomes for the second and third
evaluations, Pre-2 and Pre-3, relative to the first evaluation
(Pre-1) and for change for the Mid- and Post-evaluations
relative to Pre-3. Thus, the regression models were forced to
pass through the origin. An indicator variable was included in
the regression model to directly compare the slopes from
before and during treatment. Finally, the Follow-Up outcome
values were compared with those estimated from the
regression models for the pre-training data.
For the additional outcome measures, a summation of
scores for wrist extension, wrist flexion, finger extension and
finger flexion was calculated using the MMAS scale (0-5) for
each of the 6 evaluation sessions. The MAL was administered
once prior to treatment (Pre), immediately following treatment
(Post), and one-month later (Follow-up)-treatment. The
Quality of Movement (QOM) portion of the MAL was used
exclusively in data analysis as it has been found to be a
reliable measure of real-world arm use [40]. A rm-MANOVA
was performed with subsequent post hoc univariate ANOVAs
for outcomes showing a significant effect of evaluation. Post-
hoc pairwise comparisons with a Bonferroni correction for
multiple comparisons were conducted to further evaluate the
impact across the evaluations.
III. RESULTS
A total of 13 stroke survivors completed the 15 training
sessions and all 6 evaluation sessions. Two participants
withdrew before completion of the studyone due to personal
scheduling conflicts and one due to pain in the digits and
decreased activity tolerance while wearing the X-Glove during
the active training mode. Participants ranged in age from 43-
84 years. All but one participant had hand impairment rated as
Stage of Hand 3 on the CMSA-H; this individual had Stage of
Hand 4 (see Table I).
Despite the substantial motor impairment (mean FMUE =
16.2), participants were able to use the X-glove to complete a
significant number of therapeutic movements. Participants
were able to complete an average of 163(44) movement
repetitions per training session.
Participants exhibited improvement during the treatment,
with retention up to one-month later (for an example, see Fig.
3). Across subjects, the data for the outcome measures met the
normality assumption (Shapiro Wilk: p>0.01), so rm-
MANOVA was performed. A significant effect of Evaluation

TABLE II
MEAN OUTCOME MEASURES SCORE (SD) AT EACH EVALUATION SESSION
Outcome Measure Max Pre1 Pre2 Pre3 Mid Post Follow-up P-value
Score
Clinical Task
Performance
ARAT 57 9.9(7.0) 10.1(6.1) 10.5(6.2) 12.9(7.9) 12.4(7.9) 13.9(8.4) .020
CAHAI-9 7 1.7(1.0) 1.7(0.8) 1.8(0.8) 2.0(0.8) 2.4(1.0) 2.2(0.9) <.001
GWMFT-func 5 2.6(1.2) 2.5(1.1) 2.7(1.1) 2.9(1.2) 3.1(1.3) 3.3(1.4) .029
GWMFT-time (s) 120 69.4(31.4) 72.2(29.4) 68.3(29.4) 60.5(30.8) 56.2(30.7) 60.6(29.6) .001
Upper Extremity
Impairment
EXT (N) -- 6.0(6.2) 6.4(6.9) 6.3(6.4) 7.6(8.4) 7.5(8.2) 7.1(7.6) .590
FMUE 66 16.2(5.2) 16.2(4.9) 17.0(6.1) 18.9(4.9) 19.2(5.8) 20.1(5.3) <.001
GS(N) -- 47.6(33.7) 45.3(36.7) 52.0(33.7) 58.2(38.0) 67.3(41.6) 70.2(32.1) <.001
LPS (N) -- 21.4(17.3) 22.4(20.5) 21.9(13.3) 28.2(16.3) 32.3(20.7) 30.8(18.0) .003
PPS (N) -- 16.1(9.4) 16.3(10.9) 15.6(7.3) 20.4(11.5) 21.1(9.3) 20.2(10.9) .008
Spasticity &
Function
MMAS 20 4.0(2.2) 4.5(2.1) 4.0(2.2) 3.9(3.0) 3.8(2.9) 3.5(2.9) .280
MAL QOM 5 -- -- 0.6(0.5) -- 1.2(0.9) 1.5(1.2) .001

ARAT: Action Research Arm Test; CAHAI-9: Chedoke Arm and Hand Inventory; GWMFT-func: Graded Wolf Motor
Function Test (functional score); GWMFT-time: Graded Wolf Motor Function Test (completion time); EXT: finger extension
force; FMUE: Fugl-Meyer Assessment for the upper extremity; GS: grip strength; LPS: lateral pinch strength; PPS: palmar
pinch strength; MMAS: Modified Modified Ashworth Scale; MAL QOM: Motor Activity Log (quality of movement). P-
value is Univariate rm-ANOVA.

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Fig. 3. Select outcome measures for a single subject across evaluation sessions. (a) Chedoke Arm and Hand Inventory; (b)
Action Research Arm Test; (c) Fugl-Meyer Assesment for Upper Extremity; (d) palmar pinch strength. Trend for
improvement was greater during treatment (shaded box) than during the pre-treatment timeframe.

session was observed (Wilks lambda<0.001). Subsequent
univariate tests confirmed that this effect was present for all
outcome measures except isometric finger extension (Table
II). Post-hoc pairwise comparisons implementing a Bonferroni
correction confirmed that mid-training scores were
significantly better than the mean pre-training scores for
GWMFT functional (p=0.045) and mean completion time
(p=0.042), GS (p=0.042), LPS (p=0.031), FMUE (p=0.001),
and ARAT (p=0.014). Post-training scores continued to show
improvement over the mean pre-training scores for GWMFT
functional (p=0.003) and GWMFT mean completion time
(p=0.002), GS (p<0.001), LPS (p=0.020), FMUE (p=0.012)
and additionally for PPS (p<0.001) and CAHAI-9 (p=0.008).
At the one-month follow-up, scores were still significantly
better than mean pre-training values for CAHAI-9 (p=0.028),
FMUE (p=0.002) and GS (p<0.001).
To look at rates of change over time, we performed
regression analyses for the pooled data across subjects for the
pre-training data and the data during training. For the pre-
training data, none of the outcome measures had a significant
fit for the linear regression model (p>0.204 for each
regression) and the R2 values were quite small (less than
0.064). In contrast, for the evaluations covering the treatment
phase, all tested outcome measures, except extension strength,
exhibited significant goodness-of-fit to the regression model
(p<0.01 and R2>0.24). The magnitudes of the slopes for the
data from the training period were always greater than those
for the pre-training data. The regression model revealed
significantly greater slopes during training for PPS (p=0.04),
GWMFT-functional (p=0.029), and GWMFT-time (p=0.019),
while the LPS approached significance (p=0.059) (Fig. 4).
Projections of improvement at the one-month follow-up
evaluation were made from the regression model for the pre-
treatment data. The extrapolations of these models
underestimated the entire 95% confidence intervals for the
actual Follow-up outcomes for GWMFT-time, GWMFT-
functional score, GS, and PPS.
For the additional outcome measures, the results also
showed improvement following treatment. The rm-MANOVA
revealed a significant effect of Evaluation session (Wilks
lambda=0.002). Subsequent univariate rm-ANOVAs showed
significant changes for the MAL(QOM) (p=0.001) but not for
the MMAS (p=0.280). Mean Post-training scores for the
MAL(QOM) increased by 0.590.61 (p=0.14) and Follow-up
scores by 0.950.84 (p=0.004); both varied significantly from
the pre-training scores. MMAS showed a mean decrease of
0.461.56 and 0.691.71 for the Post- and Follow-up scores,
respectively.

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Fig. 4. Comparison of the regression models fit to the pre-training data and to the data during the training period. Data were
pooled across subjects. Asterisks denote mean for each evaluation session. Pre-training data (circles) computed as difference
with respect to first evaluation session. Training data (squares) computed as difference with respect to third pre-training
evaluation session. (a) Graded Wolf Motor Function Test time; (b) Graded Wolf Motor Function Test functional score;
(c) grip strength; (d) lateral pinch strength.

impairment demonstrated improvement in almost all of the

IV. DISCUSSION
Stroke survivors in the subacute phase of recovery
participated in a 5-week intervention combining passive
cyclical stretching of the digits with active practice of
functional tasks. Overall, participants responded well to this
treatment paradigm. While two of the participants withdrew,
both did so with reluctance. Even the subject who experienced
pain, localized at the corners of the nail bed of the fingertips,
wished to continue. Despite substantial hand impairment, the
participants who completed the study averaged over 160 hand
movements per training session. This far exceeds the number
expected in a typical therapy session in the clinic [41].
A. Impact of Treatment
The Participants with substantial
outcome measures when involved with the treatment
paradigm. Significant gains were achieved even though all but
one participant had severe hand impairment, as classified by
CMSA-H of 3, and the mean initial FMUE across all
participants was 16. In comparison, the initial FMUE for
stroke survivors in the constraint-induced EXCITE trial was
42 [5].
Importantly, we observed beneficial changes in both the
clinical performance measures and in impairment measures. In
past intervention studies for stroke survivors, there has been a
question of whether improvements resulted from remediation
of impairment mechanisms, such as weakness, or from
implementation of compensation strategies or movement
patterns [42-44]. We saw increases in grip and pinch strength
and in FMUE, as well as improvement in ARAT and
GWMFT. The increase on the ARAT represents a minimal
upper extremity detectable change (MDC) that is clinically relevant for

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translation of these findings into practice, while the MDC for
the FMUE approached clinical significance at one month [45].
The mean time to complete each task on the GWMFT dropped
by over 13 seconds following training, or 20% of the pre-
training time. Grip strength increased by almost 20 N, or 35%
of the largest pre-training value. Palmar and lateral pinch
strengths increased by 32% and 48%, respectively, after
treatment. The strength gains are important as the participants
exhibited substantial weakness, as we have previously
described in similar populations [12].
Certainly, some of this improvement may have occurred
even without the intervention, especially as the subjects were
in the subacute phase of recovery. Yet, recent cohort studies
aimed at predicting long-term outcomes following stroke
suggest stroke survivors with moderate to severe upper
extremity impairment reach a plateau in recovery roughly 3
months following stroke [46-48]. Participants were 4 months
post-stroke on average when they began this study.
Accordingly, our pre-training outcome evaluations showed
little change over time. In contrast, the outcome data collected
during treatment displayed a significant improvement over
pre-training data. These gains tended to increase from the
middle to the end of training; thereby suggesting that even
further improvement may have been possible with continued
treatment. It is interesting to note that a number of the one-
month post-therapy outcomes were greater than those
predicted by the pre-therapy regression models. While these
predictions require extrapolation from the data points used to
create the models and so may not accurately represent natural
recovery, they do provide an interesting comparison of the
actual trajectory with that expected from the pre-training
evaluations.
Given our past results [49], we believe that the stretching
helps to reduce the long flexor hyperexcitability common in
the targeted population, thereby facilitating the subsequent
active movement practice. Additionally, having to close the
digits against the extension assistance may actually have
helped to increase strength, as suggested by a study
implementing resistance training in stroke survivors [50]. In
accordance with that study, we saw no significant change in
spasticity as measured with the MMAS. Thus, the treatment
did not appear to exacerbate hyperexcitability. Extension force
was the only strength measurement that did not show
significant improvement. It is possible that more directly
targeting the extensors with resistance training would be
beneficial.
B. Study Limitations
We reiterate that for this study each participant served as
his/her control; there was no separate control group. At the
subacute phase of recovery the stroke population is especially
heterogeneous in terms of treatment history and ongoing life
situations. Comparison between changes in outcome measures
before and after intervention for each participant seemed to
afford the most direct evaluation of the treatment. As all
participants had received therapy in both inpatient and
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7
outpatient rehabilitation settings prior to enrolling in this
study, the gains achieved suggest an effect of the specific
treatment we imposed. The positive results provide impetus
for a future clinical trial with a matching control group.
Pre-training data were collected over two weeks prior to
initiation of treatment rather than over a longer period as we
wished to start training as early as possible to maximize
benefits. While one might argue that this period was too short
to detect ongoing changes, the Mid-evaluation data were
collected at 3 weeks after the initiation of treatment, and at
this point a number of the outcome measures exhibited
significant improvement.
While positive outcomes were observed at one-month
following the end of treatment, it is not known if they were
maintained beyond this point. Intriguingly, the rate of
improvement observed between the Mid and Post sessions was
typically as great as that seen between the Pre-3 and Mid
evaluations. This suggests that further improvement might be
obtained with more treatment sessions. A future study with a
longer treatment period and a longer follow-up period seems
warranted.
V. CONCLUSION
Our results suggest that use of an actuated device, which
can be incorporated directly into clinical therapy, may be
beneficial for facilitating rehabilitation. Stroke survivors with
severe hand impairment may benefit from a combination of
passive cyclical stretching and targeted assistance of active
movements. This paradigm affords participants and their
therapists the opportunity to maximize rehabilitation of motor
control by providing skilled, task-oriented therapy in the clinic
that may not otherwise be attempted for stroke survivors with
this level of impairment. This seems to be particularly
essential during the subacute phase of recovery [51].
APPENDIX
A detailed description of the task-oriented protocol used in
the intervention for this study is available in the online version
of this manuscript.
ACKNOWLEDGMENT
The authors would like to thank Molly Corrigan, MS,
OTR/L, for her assistance with training sessions and Dr.
Catherine Lang, PT, PhD, for her assistance with study design.
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TNSRE-2015-00086.R2 9

shoulder abduction within 72 hours after stroke predicts functional Kelly O. Thielbar received her B.S
recovery: early prediction of functional outcome after stroke: the EPOS degree in Psychology from the University
cohort study," Stroke, vol. 41, pp. 745-50, Apr 2010. of Illinois in Champaign-Urbana in 2006
[47] C. E. Lang, S. L. DeJong, and J. A. Beebe, "Recovery of thumb and
finger extension and its relation to grasp performance after stroke," J
and M.S. degree in occupational therapy
Neurophysiol, vol. 102, pp. 451-9, Jul 2009.
from Washington University in St. Louis
[48] J. A. Beebe and C. E. Lang, "Active range of motion predicts upper in 2010.
extremity function 3 months after stroke," Stroke, vol. 40, pp. 1772-9, From 2010 to the present she has
May 2009. been an Occupational Therapist at the
[49] K. M. Triandafilou, H. C. Fischer, J. D. Towles, D. G. Kamper, and W. RIC. She has had a position as a research
Z. Rymer, "Diminished capacity to modulate motor activation patterns Occupational Therapist in the Coleman Hand Rehabilitation
according to task contributes to thumb deficits following stroke," J Lab since 2011. Her research interests include upper
Neurophysiol, vol. 106, pp. 1644-51, Oct 2011. extremity neurorehabiliation and functional recovery post
[50] C. Patten, E. G. Condliffe, C. A. Dairaghi, and P. S. Lum, "Concurrent stroke.
neuromechanical and functional gains following upper-extremity power
training post-stroke," J Neuroeng Rehabil, vol. 10, p. 1, 2013.
[51] C. Stinear, S. Ackerley, and W. Byblow, "Rehabilitation is initiated Jos M. Ochoa (M87) received the B.S.
early after stroke, but most motor rehabilitation trials are not: a degree in biomedical engineering from
systematic review," Stroke, vol. 44, pp. 2039-45, Jul 2013. Antioquias School of Engineering,
Envigado, Antioquia-Colombia, in 2009
Heidi C. Fischer received a B.S. in and the M.S. degree in mechanical
Psychology at the University of Illinois at engineering from Northwestern
Urbana-Champaign in 1997 and M.S. and University, Evanston, IL, in 2014.
Doctoral degrees in occupational therapy He is currently working as a research
from the University of Illinois at Chicago engineer at the RIC. His research interest
in 2000 and 2015. includes the development and control of robotic prosthesis and
From 2000 to 2004, she was clinical orthosis using biological signals.
occupational therapist at the
Rehabilitation Institute of Chicago (RIC). Emily D.C. Lazzaro received the B.S
In 2003, she was a research occupational degree in mechanical engineering from
therapist in the Hand Rehabilitation Laboratory and the ARM the University of Virginia in
Guide Laboratory at RIC until 2005, when she became Charlottesville, Virginia in 2002 and a
Clinical Research Coordinator for the Hand Rehabilitation Clinical Doctorate in physical therapy
Laboratory and for a research project in the RIC Center for from the University of Miami in Coral
Outcomes Research. From 2009 to 2011, she served as Quality Gables, Florida in 2009.
Consultant for the American Occupational Therapy From 2009 to 2015, she was a physical
Association. In 2014, she became Clinical Assistant Professor therapist and clinical research coordinator
in Occupational Therapy at the University of Illinois at in the RIC. Her research interests include devices to improve
Chicago. She is co-author of 20 articles, and presented at 15 patient outcomes and safety for patients and therapists in the
national and international conferences. Her research interests clinical environment. She now works as a Clinical Specialist
include improving self-advocacy and participation following with Bioness.
stroke through occupational therapy self-management
interventions, the use of technology and task-oriented Kathleen A. Pacholski received the B.A.
occupational therapy to promote upper extremity function degree in English at Thomas More
following stroke. College in Crestview Hills, Kentucky in
Dr. Fischer was a University Fellow at the University of 1983.
Illinois at Chicago 1997 to 1999, recipient of the Sarah Baskin From 1985 to 1993 she was the
Research Award at RIC in 2008 and is a member of the manager and director of IIT/V, IITs
American Occupational Therapy Association. Interactive Instructional Television
Network. She is currently working as a
Kristen M. Triandafilou (M04) research assistant in the Hand Lab and
received the B.S. and M.S. degrees in the Single Motor Unit (SMU) Lab at the RIC.
electrical engineering from the Illinois
Institute of Technology, in 2004 and Derek G. Kamper (M97) received the
2009, respectively. B.E. degree in electrical engineering from
She is currently working as a Dartmouth College, Hanover, NH, in
biomedical engineer at the RIC. Her 1989, and the M.S. and Ph.D. degrees in
research interest includes the biomedical engineering from The Ohio
development and control of soft robotics
using biological signals for neurorehabilitation, mechatronics, State University, Columbus, OH, in 1992
and upper extremity neuromechanics. and 1997, respectively.
Ms. Triandafilou was recipient of the Achievement He then completed a postdoctoral
Rewards for College Scientists (ARCS) fellowship in 2008 fellowship at the Rehabilitation Institute
and 2009, the Illinois Institute of Technology Research of Chicago. He is currently an Associate Professor in the
Scholarship (IITRS) from the Armor College of Engineering Department of Biomedical Engineering at the Illinois Institute
at IIT in 2005, and Abstract was honored at the American of Technology, Chicago, IL. His research interests include
Society of Biomechanics (ASB) Annual meeting in 2011.
neurorehabilitation, mechatronics, and upper extremity
neuromechanics.

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