ARTICLE IN PRESS

Virtual Reality in Upper Extremity Rehabilitation of Stroke

Patients: A Randomized Controlled Trial

D1X XSevgi Ikbali Afsar, D2XAssoc.

X Prof.,* D3X XIlkin Mirzayev, MD, D4X X †
D5X XOya Umit Yemisci, Assoc.
D6X X Prof.,* and D7X X
Sacide Nur Cosar Saracgil, D8XAssoc. X Prof.*

Objective: Virtual reality game system is one of novel approaches, which can
improve hemiplegic extremity functions of stroke patients. We aimed to evaluate
the effect of the Microsoft Xbox 360 Kinect video game system on upper limb motor
functions for subacute stroke patients. Methods: The study included 42 stroke
patients of which 35 (19 Virtual reality group, 16 control group) completed the
study. All patients received 60 minutes of conventional therapy for upper extrem-
ity, 5 times per-week for 4 weeks. Virtual reality group additionally received Xbox
Kinect game system 30 minutes per-day. Patients were evaluated prior to the reha-
bilitation and at the end of 4 weeks. Box&Block Test, Functional independence mea-
sure self-care score, Brunnstorm stage and Fugl-Meyer upper extremity motor
function scale were used as outcome measures. Results: The Brunnstrom stages and
the scores on the Fugl-Meyer upper extremity, Box&Block Test and Functional inde-
pendence measure improved significantly from baseline to post-treatment in both
the experimental and the control groups. The Brunnstrom stage-upper extremity
and Box&Block Test gain for the experimental group were significantly higher com-
pared to the control group, while the Brunnstrom stage-hand, the Functional inde-
pendence measure gain and Fugl-Meyer gain were similar between the groups.
Conclusions: We found evidence that kinect-based game system in addition to conven-
tional therapy may have supplemental benefit for stroke patients. However, for virtual
reality game systems to enter the routine practice of stroke rehabilitation, randomized
controlled clinical trials with longer follow-up periods and larger sample sizes are
needed especially to determine an optimal duration and intensity of the treatment.
Key Words: Hemiplegia—stroke rehabilitation—upper extremity—virtual reality
© 2018 National Stroke Association. Published by Elsevier Inc. All rights reserved.

Introduction level of functional independence. Stroke patients with

Stroke is one of the main causes of years lived with dis-
ability in adults.1 Stroke rehabilitation needs to develop
new approaches in order to help individuals gain higher
From the *Baskent University, Faculty of Medicine, Physical Medi-
cine and Rehabilitation Department, Ankara, Turkey; and †Ilke Hos-
pital, Physical Medicine and Rehabilitation, Y{ld{r{mbeyaz{t Cad.
No:56 Yenibosna/Bahçelievler, Istanbul, Turkey.
Received April 24, 2018; revision received July 25, 2018; accepted
August 5, 2018.
Address correspondence to Sevgi Ikbali Afsar, Baskent University,
Faculty of Medicine, Physical Medicine and Rehabilitation Depart-
ment Ankara, M. Fevzi Cakmak Cad. 5. Sok. No:48, Bahcelievler
06490, Ankara, Turkey. E-mail: ikbaliafsar@hotmail.com
1052-3057/$ - see front matter
© 2018 National Stroke Association. Published by Elsevier Inc. All
rights reserved.
https://doi.org/10.1016/j.jstrokecerebrovasdis.2018.08.007
upper extremity functional limitation are particularly sus-
ceptible to problems in performing daily living activities.2
Several treatment options are available for patients after
stroke, with varying levels of evidence to support them.
Task-oriented, repetitive training with cognitive participa-
tion that become increasingly complex have been shown
to increase motor improvement by stimulating cortical
reorganization in stroke rehabilitation especially when
the overall therapy time is increased.3 Virtual reality (VR)
game systems create a simulation model that provides the
participants the feeling that the environment is real and
allows mutual communication with the dynamic environ-
ment created by computers.4 These systems offer the
opportunity to work with task-based techniques by creat-
ing a stimulating and entertaining environment and
ensuring interest and motivation.5 They are superior to
conventional rehabilitation methods in terms of providing

Journal of Stroke and Cerebrovascular Diseases, Vol. &&, No. && (&&), 2018: pp 1 6 1
 ARTICLE IN PRESS
2 S. IKBALI AFSAR ET AL.
the exercise intensity required to induce neuroplasticity.
However, because of the cost of the VR systems is high; it
is difficult to use these nonpractical devices. Motion-con-
trolled video games have become an increasingly com-
mon adjunct to physical therapy and show potential as
feasible and effective poststroke treatment options.6 There
are 3 different commercial game consoles in common use
at present; Sony Playstation II EyeToy, Nintendo Wii, and
Microsoft Xbox 360 Kinect. Of these systems, Microsoft
Xbox 360 Kinect differs from the others with its advanced
camera technology that can perceive the body and
extremity movements sensitively in 3-dimensions without
requiring a remote control or an active/passive marker. It
is therefore suitable for a study program design, espe-
cially in patients with affected extremity functions.
Although there is a substantial amount of research in
areas of developing VR and specific games for stroke
patients, there is limited evidence for the therapeutic utility
of these video game consoles. Previous studies have found
VR intervention to be a less effective approach than conven-
tional therapy in retraining upper limb function. However,
this was considered to have low quality evidence.7 In these
game consoles, the Xbox Kinect is relatively newest. The
games played with Xbox Kinect can furnish interventions to
improve motor function, balance, gait, and depression.2,8,9,10
Two recent studies using the Xbox Kinect gaming sys-
tem have shown that kinect-based games are effective in
upper extremity rehabilitation in stroke patients.2,8 The
aim of this study was to evaluate the effect of VR training
by using the Xbox Kinect game system in addition to a
conventional rehabilitation on upper extremity motor
functions in subacute stroke patients.
Materials and Methods
Subjects
The study was conducted at a tertiary level rehabilita-
tion center affiliated with Baskent University Hospital.
First-time stroke patients who were admitted to the inpa-
tient rehabilitation facility between April 2014 and March
2015 were included in our study. Stroke was diagnosed
by a neurologist based on the clinical features as sup-
ported by computed tomography (CT) or magnetic reso-
nance imaging findings.
Inclusion criteria were as follows: (1) a first episode of
unilateral stroke with hemiparesis, (2) stroke duration less
than 6 months and more than 1 month, (3) medically sta-
ble enough to participate in active rehabilitation, (4) mild-
to-moderate motor upper extremity deficits (Brunnstrom
stage for the upper extremity
3), (5) ability to execute at
least 20 degrees of active shoulder flexion and abduction
against gravity, (6) no problems with auditory or visual
functioning, and (7) a total score of 23 or greater on the
Mini Mental State Examination.11
Patients were not included in the study if they had
severe conditions such as uncontrolled blood pressure or
angina, history of epilepsy, any intervention other than
conventional therapy, or the refusal to play a video game.
This study was approved by the University Institu-
tional Review Board and Ethics Committee (Project no:
KA14/79) and carried out according to the institutional
guideline and principles of the Declaration of Helsinki.
The study was supported by the University Research
Fund. All subjects understood the purpose of this study
and provided their written informed consent prior to their
participation in the study. The study had 90% power with
5% type 1 error when a difference of 4.4 units between the
Fugl-Meyer Assessment upper extremity (FMA-UE)
scores of the groups was accepted as clinically significant.
Procedures
The patients were randomly divided into 2 groups after
the baseline evaluations were performed, as the experi-
mental group and control group by using random num-
bers created by the computer. The random number
program was managed by a physician who was blinded
to the study protocol and did not participate in the study.
The patients and the physiotherapist who supervised
game playing were not blinded due to the nature of the
study. Before and after the intervention, the patients were
measured for muscle function, gross manual dexterity,
and performance of activities of daily living.
Interventions
Both the experimental group and the control group
underwent a conventional rehabilitation program 5 days
per week, for a total of 4 weeks.
The experimental group participated in a VR training
using Xbox Kinect in addition to conventional therapy.
Xbox Kinect system (XBOX 360, Kinect, Microsoft Inc) is a
commercial video game technology that provides body
control of animated virtual characters. This device can rec-
ognize and track user movements in real time without
requiring a special controller, through an infrared camera
sensor. It does not require buttons to be pressed for move-
ment to be recognized, enabling users with impaired
motor skills also play the game in an effective manner.
The Xbox Kinect, console, and monitor were set up in an
isolated and quiet room so that external factors would not
influence the results. The patient sat on a wheelchair 1.5-2
m away from the Kinect sensor. Patients were informed
about the game by the physiotherapist before the training
session was started and they were shown how to play.
For the VR training, the following games were used;
Mouse Mayhem, Traffic Control, Balloon Buster, and
Mathercising from Dr. Kawashima's Body and Brain Exer-
cises package. The programs required active movements
of the upper extremity. The patients actively performed
bilateral shoulder abduction and adduction, and active
elbow flexion and extension movements in the “Mouse
Mayhem” and “Traffic Control” games. They actively
 ARTICLE IN PRESS
VIRTUAL REALITY FOR STROKE REHABILITATION
performed flexion and extension movements in both the
shoulder and elbow joints in the “Balloon Buster” and
“Mathercising” games. Programs continued for a total of
30 minutes per session. During the 4 weeks of the inter-
vention, participants used all the provided games.
Conventional rehabilitation program aimed to normal-
ize movement patterns and minimize spasticity. Physical
therapy included static and dynamic control of position,
balance skills, weight shift, and activities of daily living.
Moreover, proprioceptive neuromuscular facilitation and
neurodevelopmental facilitation techniques were selected
by the physical therapists based on the requirement of
each patient. The program was performed for 60 minutes.
Evaluation
The assessments were made by a trained occupational
therapist who was blinded to the patients’ randomization
and not involved in the administration of the study inter-
ventions.
Primary Outcome Measures
In this study, the motor function of the upper extremity
was evaluated using upper extremity subscale of the
Fugl-Meyer Assessment (FMA-UE). FMA-UE is designed
to quantitatively assess stroke patients’ motor function
and includes upper and lower extremity motor function
tests and sensory tests.12 The FMA-UE includes 33 items
to evaluate upper extremity motor impairment and is
scored between 0 and 2 (0 = unable, 1 = partly able, and
2 = fully able to complete movement) with a total score
range of 0-66. It was reported that reliability of the FMA
for testing motor performance in patients following stroke
is high.13
Secondary Outcome Measures
Secondary outcome measures included the Brunnstrom
stage of recovery, the Box and Block Test (BBT) and the
self-care subscores of the Functional Independence Mea-
sure (FIM).
Brunnstrom staging is a test evaluating the motor
development of hemiplegic patients. The upper extremity,
hand and lower extremity are evaluated separately. The
lowest stage is identified as stage 1 (flask, no voluntary
movement) and the highest stage as 6 (isolated joint
movement present).14 We evaluated the upper extremity
and hand Brunnstrom stages of the patients in this study.
Gross manual dexterity was measured by the BBT, in
which the subjects are asked to move as many 2.5 cm
blocks as they can as quickly as possible using only the
thumb and index fingers during a timed 60 s trial.15 The
BBT test has excellent reliability (Intrarater reliability is
r = .99 (left) and r = 1.00 (right)).17,18
The FIM instrument is widely used for measuring activ-
ity limitation through performance observation in terms
3
of how much help the subject requires to perform basic
activities. It contains 18 items that measure independent
performance in self-care, sphincter control, transfers, loco-
motion, communication, and social cognition. FIM is
scored from 1 to 7. A score of 7 means “complete indepen-
dence” and 1 means “complete dependence” (performs
less than 25% of the tasks).16 We used the FIM self-care
subitems in this study and the total score was 6-42. The
reliability and validity of the Turkish version of the FIM
has been documented.19
Statistical Analysis
The SPPS 20 (IBM Corp. Release 2011. IBM SPSS Statis-
tics for Windows, Version 20.0. Armonk, NY: IBM Corp.)
statistical software program was used in the evaluation of
the data. Mean § standard deviation and median (maxi-
mum-minimum) percentage and frequency values of the
variables were used. The variables were evaluated (using
the Shapiro-Wilk and Levene tests) following checks for
the preliminary conditions of normality and homogeneity
of the variances. When comparing 2 groups, we used the
test of difference between 2 independent groups (Stu-
dent's t test) if the parametric test conditions were met
and the Mann Whitney U test otherwise for data analysis.
When comparing pretreatment and post-treatment val-
ues, the test of difference between 2 dependent groups
(paired t test) was used if the parametric test conditions
were met and the Wilcoxon test otherwise. Categorical
data were analyzed with Fisher's exact test and chi-square
test. We used the “Monte Carlo Simulation Method” to
include any small frequencies in the analysis when the
expected frequencies were smaller than 20%. A P value
< .05 was accepted as the significance level for the tests.
Results
A total of 92 patients were screened for the study.
Forty-two participants who met the inclusion criteria
were divided into 2 groups; the experimental group
(n = 21) and control group (n = 21). There were 7 drop-
outs because of early discharge from the hospital and they
were excluded in the analysis. The 35 patients who com-
pleted the study consisted of 15 females and 20 males.
Demographic characteristics of the patients are shown in
Table 1. No statistically significant difference was found
between the groups in terms of age, gender, dominant
hand, paretic hand, lesion type, and duration since the
stroke (P > .05). Both groups were similar at baseline in
terms of Brunnstrom stages, BBT scores and FIM self-care
subscores (P > .05), but the FMA-UE score was higher in
the experimental group (P = .04). At post-treatment, a sta-
tistically significant increase was found in both groups in
the upper extremity and hand Brunnstrom stages, FMA-
UE, FIM self-care subscore, and BBT score (P < .001).
The post-treatment Brunnstrom stage of upper extrem-
ity, FMA-UE and BBT scores were significantly higher in
 ARTICLE IN PRESS
4 S. IKBALI AFSAR ET AL.

Table 1. Demographic characteristics of the patients

Variables Experimental group (n = 19) Control group (n = 16) P value

Age (years) (mean § SD) 69.42 § 8.55 63.44 § 15.73 .19
Disease duration (days) (mean § SD) 88.32 § 56.32 68.63 § 39.20 .25
Sex (female/male) 7/12 8/8 .43
Dominant side (right/left) 17/2 14/2 .85
Hemiplegic side (right/left) 5/14 6/10 .47
Etiology (infarction/ hemorrhage) 15/4 12/4 .78

Table 2. Between-group differences of Brunnstrom stage change scores

Experimental group (n = 19) Control group (n = 16) P value

Brunnstrom-arm
Pretreatment, median (range) 3 (3-4) 3 (3-4) .19
Post-treatment, median (range) 5 (3-6) 4 (3-5) .03*
Brunnstrom-hand
Pretreatment, median (range) 3 (3-4) 3 (3-4) .31
Post-teatment, median (range) 5 (3-6) 4 (3-5) .24
*P < .05.

the experimental group than the control group, but no sta-
tistically significant difference was found between the 2
groups regarding the Brunnstrom stage of hand and FIM
(Tables 2 and 3).
For the experimental group, the change of BBT (pre-to-
post difference) scores showed a significant improvement
when compared to the control group (P = .007). However,
the change of FMA-UE and the FIM scores for the experi-
mental group were not significantly higher than the con-
trol group (P = .057, P = .677) (Table 4).
Discussion
The aim of stroke rehabilitation is to support the resto-
ration of movement by activating new motor projection
regions and resting synapses. Sensory stimuli, and stimu-
lants at various levels such as the cognitive planning of
motor activity and movement lead to permanent cellular,
anatomical, physiological, and behavioral restructuring of
the CNS.20 Intense, repetitive, and targeted movements
are performed with VR gaming systems. The strength
increase occurs especially in the affected upper extremity
with active movement of the patient.10
The results of our study showed a statistically signifi-
cant improvement in upper extremity Brunnstrom stage
and BBT scores in the experimental group than the control
group. Although it was not a statistically significant dif-
ference; the FMA-UE gain was also better in the experi-
mental group than the control group. However there was
no statistically significant difference between the 2 groups
regarding FIM scores and hand Brunnstrom stages. Simi-
larly, other studies have revealed a better motor improve-
ment in upper extremity proximal muscle groups in the
VR group compared with the control group.2,8 These
results may be explained by the fact that during the BBT;
upper extremity proximal muscle group movement is
required for the patient to move the boxes across the sepa-
rator set. Similarly an increase in post-treatment

Table 3. Clinical parameters of before and after treatment

Experimental group (n = 19) Control group (n = 16) P value

FMA upper extremity score
Pretreatment, mean (range) 24.32 § 7.87 (10-36) 19.88 § 3.79 (12-25) .04*
Post-treatment, mean (range) 43.05 § 12.59 (20-60) 34.44 § 10.53 (18-59) .04*
BBT score
Pretreatment, mean (range) 12.74 § 5.09 (4-21) 12.19 § 3.75 (9-21) .72
Post-treatment, mean (range) 28.53 § 11.15 (12-44) 20.81 § 10.03 (11-44) .04*
FIM self-care score
Pre-treatment, mean (range) 12.74 § 2.51 (10-15) 13.63 § 3.61 (10-22) .40
Post-treatment, mean (range) 23.74 § 4.42 (20-29) 23.63 § 4.99 (15-33) .95
Abbreviations: BBT, Box and Block test; FIM, Functional Independence Measure; FMA, Fugl-Meyer Assessment.
*P < .05
 ARTICLE IN PRESS
VIRTUAL REALITY FOR STROKE REHABILITATION
Table 4. Changes in upper extremity function between before and after treatment
Experimental group (n = 19)
Delta-FMA upper extremity score 18.74 § 7.67
Delta-BBT score 15.47 § 6.90
Delta-FIM self-care subscore 11 § 3.16
Abbreviations: BBT, Box and Block test; FIM, Functional Independence Measure; FMA, Fugl-Meyer Assessment.
Values are expressed as mean § standard deviation.
*P < .05.
Brunnstrom stage scores of the upper extremity in this
study also supports the increase in the BBT scores. These
results may be related to the use of the proximal portion
of the arm in kinect-based VR training. Also the absence
of improvement in the hand Brunnstrom stages can be
explained by the light of this information; because there is
a mismatch between the intended target and the evalua-
tion parameter. In future studies, more specific programs
should be prepared for the development of hand skills.
The possible mechanism of VR therapy in increasing
upper extremity motor functions is thought to be the
increased reorganization of the brain while using the
paretic extremities.21 These systems also provide visual
and auditory biofeedback.2 Furthermore motivating and
entertaining games also make VR therapy attractive for
the patients.22
Bao et al evaluated the effects of VR therapy using Xbox
Kinect on cortical reorganization of 5 subacute stroke
patients. A significant increase was found in the post-
treatment FMA scores. Functional magnetic resonance
imaging images of the patients before and after the treat-
ment were recorded, and an increased activation was
found in contralateral sensory motor cortexes in the VR
group during follow-up; however the control group had
no MR images.10
Sin and Lee conducted a randomized controlled trial to
test the ability of Xbox Kinect to assist upper extremity
rehabilitation in patients with chronic stroke. VR therapy
was administered to the patients for 30 minutes/day in
addition to occupational treatment, 3 times a week for 6
weeks. While both groups displayed significant improve-
ments in the FMA and BBT scores and active ROMs of
shoulder, the VR group demonstrated significantly
greater improvements than the control group in all out-
comes except wrist ROM at the end of the study.2
Lee evaluated the change in upper extremity muscle
strength, tonus, and daily living activities in patients with
chronic stroke to determine the effectiveness of the VR
training using Xbox Kinect. Conventional therapy and VR
training durations were similar to the previous study. In
the VR group, the upper limb muscle strength showed
significant improvement compared to baseline, except for
the wrist. FIM scores also improved significantly in the
VR group compared to baseline. However, no significant
difference was found between the groups at post-test.8
5
Control group (n = 16) P value
13.94 § 6.58 .057
8.63 § 7.03 .007*
10.33 § 3.79 .677
In our study, the FMA-UE scores of the patients in both
groups improved compared to the pretreatment. How-
ever, although the VR group showed significant change
in Brunnstrom stages; the change of FMA-UE score for
the VR group was not significantly higher than the control
group. Unfortunately this is a point in our study about
which we have no conclusive explanation. Both groups
were similar at baseline in terms of Brunnstrom stages,
however the FMA-UE scores were significantly higher in
the experimental group (P = .04). This might be the reason
why FMA-UE scale may be insufficiently sensitive to doc-
ument change in high-functioning individuals. On the
other hand a change of between 4 and 7 points in chronic
stroke,23 and 9-10 points in subacute stroke is considered
to be clinically significant.24 Inadequate sampling size,
short duration of treatment, and short follow-up may also
be among other reasons.
Our results also showed a significant increase in FIM
scores after treatment in both groups, but there was no
statistically significant difference between the groups.
Plasticity related to repeated muscle activities occurs as a
result of long-term performance of such activities and
can contribute to functionality as a result of corticomotor
reorganization. Despite the increased improvement in
motor function in the experimental group, this may not
have provided adequate coordination and muscle
strength that would be reflected in the daily living activi-
ties and independence levels of the patients. The lack of
long-term follow-up may therefore cause misinterpreta-
tion of the results. Another important cause for these
results may that the games were not created specifically
for rehabilitation.
The study has some limitations. The first limitation was
that the duration of treatment in the study group was longer
than in the control group as VR therapy was added to con-
ventional rehabilitation. The longer duration of rehabilita-
tion can affect functional outcomes. Another limitation, as in
other studies, was that the Xbox Kinect system and the
games used in the study were not developed specifically for
stroke patients. There is insufficient data regarding the dura-
tion and frequency of treatment with these games as they
are not specific to stroke rehabilitation. Finally, another limi-
tation was that the effects on long-term functional develop-
ment could not be evaluated as we only the patients were
only followed-up for 4 weeks. In addition, the low number
 ARTICLE IN PRESS
6 S. IKBALI AFSAR ET AL.
of patients included in the study also prevents the generali-
zation of our results.
In conclusion, the results indicate that Kinect-based
gaming therapy contributes to upper extremity motor and
functional recovery when implemented in addition to
conventional rehabilitation in subacute stroke patients.
This treatment was not superior to the control group in
the improvement of daily living activities, but these
results may change with long term follow-up. The results
are consistent with other studies in the literature and sup-
port the potential use of VR therapy in the rehabilitation
of stroke patients. However, VR therapy can only be used
in some patients. Patients whose cognitive functions are
preserved at a level permitting communication through
the game console should be selected for this program.
There are a few questions that need clarification, such as;
can Xbox Kinect routinely be used in stroke therapy, and
which games will be available and how long and how
intense should the therapy be. Randomized controlled
clinical studies with longer follow-up in larger popula-
tions that also test the duration and intensity of the games
are required for this purpose. Further studies are needed
to develop specially designed games for stroke patients.
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