web-based telerehabilitation for the upper extremity after stroke

102 IEEE TRANSACTIONS ON NEURAL SYSTEMS AND REHABILITATION ENGINEERING, VOL. 10, NO. 2, JUNE 2002

Web-Based Telerehabilitation for the UpperExtremity After Stroke

David J. Reinkensmeyer, Member, IEEE, Clifton T. Pang, Jeff A. Nessler, and Christopher C. Painter

Abstract—Stroke is a leading cause of disability in the UnitedStates and yet little technology is currently available for individ-uals with stroke to practice and monitor rehabilitation therapyon their own. This paper provides a detailed design description ofa telerehabilitation system for arm and hand therapy followingstroke. The system consists of a Web-based library of statustests, therapy games, and progress charts, and can be used witha variety of input devices, including a low-cost force-feedbackjoystick capable of assisting or resisting in movement. Data fromhome-based usage by a chronic stroke subject are presented thatdemonstrate the feasibility of using the system to direct a therapyprogram, mechanically assist in movement, and track improve-ments in movement ability.

Index Terms—Biomechanics, computer-based training, micro-computer applications, motion control, patient rehabilitation,telemedicine.

I. INTRODUCTION

EACH YEAR in the United States, over 600 000 peoplesuffer a stroke [1]. Approximately 80% of acute stroke sur-

vivors lose arm and hand movement skills [2]. Movement im-pairments are typically treated with intensive, hands-on phys-ical and occupational therapy for several weeks after the initialbrain injury. Unfortunately, due to economic pressures on theUnited States health-care system, stroke patients are receivingless therapy and going home sooner. The ensuing home rehabil-itation is often self-directed with little professional or quantita-tive feedback.

Even as formal therapy declines, a growing body of evidencesuggests that both acute and chronic stroke survivors canimprove movement ability with intensive, supervised training.This evidence comes in part from studies of “constraint-in-duced therapy” [3]–[7] and “robot-assisted therapy” [8]–[12].In constraint-induced therapy the patient’s less impaired armis restrained, and the patient intensively practices movingthe more impaired arm, with feedback from a therapist [7].Constraint-induced therapy improves functional use [3]–[5]and expands cortical representation of the exercised limb [6].

Robot-assisted therapy refers to the use of robotic devices(sometimes called “rehabilitators”) that physically-interact

Manuscript received March 28, 2001; revised February 26, 2002. This workwas supported by grants from the Microsoft Corporation and the Parker-Han-nifin Corporation.

D. J. Reinkensmeyer, J. A. Nessler, and C. C. Painter are with the De-partment of Mechanical and Aerospace Engineering, Center for BiomedicalEngineering, University of California, Irvine, CA 92697-3975 USA (e-mail:[email protected]).

C. T. Pang was with the Department of Mechanical and Aerospace Engi-neering, Center for Biomedical Engineering, University of California, Irvine,CA 92697-3975 USA. He is now with KLA-Tencor, San Jose, CA 95134 USA.

Publisher Item Identifier S 1534-4320(02)05944-2.

with patients in order to assist in movement therapy [13], [14].In the first clinical trial of robot-aided neurorehabilitation, aplanar, two-revolute-joint robot named MIT-MANUS assistedacute stroke patients in sliding their arms across a tabletop[8], [9]. The subjects performed a daily series of movementtasks such as moving to targets and tracing figures, receivingmechanical assistance from the robot if needed. It was foundthat patients who received robot-assisted therapy experiencedgreater recovery than those receiving a sham exposure tothe robot, according to a clinical scale of arm movementability. Encouragingly, a subsequent study indicated that theserelative improvements were maintained in the robot group at athree-year follow-up [10].

Subsequent studies of other rehabilitators have producedsimilar results with chronic stroke patients. The MIME deviceused an industrial robot arm to manipulate patients’ arms [15].Chronic stroke subjects who exercised three hours per weekfor two months with the device improved movement abilitymore than a control group that received a matched amount oftraditional occupational therapy exercise [11], [16]. The ARMGuide is a singly actuated three degrees-of-freedom device forassisting in reaching movements in three dimensions across theuser’s workspace [17]. Chronic stroke subjects who receiveda two-month program of active-assist therapy with this devicealso improved arm movement ability [12], [18], [19].

Although constraint-induced and robot-assisted therapy aredissimilar in many aspects, they share a common principle: theyboth rely on intensive, repetitive practice of functional move-ment by the patient, accompanied by ongoing feedback by thetherapist or robotic device. Our working hypothesis is that in-tensive, guided practice is the primary stimulus of the observedrecovery in both therapies. This hypothesis is consistent withseveral other studies that have observed improvement in armand hand movement ability after stroke with repetitive move-ment practice [20]–[22].

If intensive, guided practice is the primary stimulus ofrecovery, an important goal for rehabilitation engineering is todevelop technology that allows the burgeoning United Statesstroke population to achieve such practice without the expenseof a supervising therapist or sophisticated robotic device.This paper describes a low-cost highly accessible system forfacilitating repetitive movement therapy. This system is called“Java Therapy” because of its use of the Java programminglanguage. Users log on to the system using the Web, performa customized program of therapeutic activities, and receivequantitative feedback of their rehabilitation progress. A re-mote supervising caregiver can then monitor progress, make

1534-4320/02$17.00 © 2002 IEEE

REINKENSMEYERet al.: WEB-BASED TELEREHABILITATION FOR THE UPPER EXTREMITY 103

Fig. 1. Use of a force feedback joystick, clip-on splint, and armrest with JavaTherapy.

changes to the exercise program, and provide informationand encouragement. The system can be used with a varietyof input devices, including a low-cost force-feedback joystickcapable of assisting or resisting in movement. The system iscomparable in concept to the force-feedback, telerehabilitationsystem for orthopedic hand impairment described in [23],but differs in its target population, mechanical structure, andsoftware design. For example, the system described in thispaper utilizes mass-manufactured input devices, existing Webinfrastructure, and Java applets, with consequent benefits inaffordability, accessibility, and adaptability. The following isa detailed description of the system design and an example ofuse of the system by a chronic stroke subject. Portions of thiswork have been reported previously in conference paper format[24], [25].

II. SYSTEM DESIGN

A. Input Devices

The Java Therapy system track users’ arm movement throughthe use of a computer input device. Possible devices that can beused with the system include traditional mechanical mice, wire-less gyroscopic mice, force feedback mice, and force feedbackjoysticks. In developing the prototype system, we have focusedinitially on a low-cost commercial force feedback joystick (Log-itech Wingman Forcefeedback Pro) (Fig. 1). This joystick canapply up to 10 N in order to resist or assist in movement and canbe programmed to implement a variety of force effects such assprings, dampers, and constant forces, which are controlled bya resident microprocessor.

Several additions were required in order to make the joy-stick usable by most individuals with a brain injury. In orderto accommodate individuals lacking hand grasp ability, left-and right-handed orthopedic splints were designed to clip onto the preexisting handle. These splints are U-shaped, made ofthermoplastic, mate securely with the joystick handle withoutusing fasteners, and have straps that secure the joystick to thehand. To help support the weight of the arm, a commercially

available articulating armrest (Ergorest, Oscar Dellert AB, Fin-land) was also incorporated. Both the joystick and armrest canbe secured to a support surface through the use of a customdesigned base.

The resulting system constrains the arm into a similar posturefor each use, and allows comfortable movement of the hand in a10 cm 10 cm workspace in the horizontal plane. The primaryjoint motions used to move the joystick are shoulder internal/ex-ternal rotation and shoulder and elbow flexion/extension. At thetime of this writing, the total cost of the force feedback joystickconfiguration is approximately US$240 (joystick$100, arm-rest $100, splint $30, base $10).

B. User Interface

The Java Therapy user interface has four key elements:statusteststhat measure rehabilitation progress,therapy gamesthatprovide a means to practice movement therapy,progress chartsthat inform users of their rehabilitation progress, and atherapistpagethat allows rehabilitation programs to be prescribed andmonitored (Fig. 2).

1) Status Tests:The purpose of status tests is to assess spe-cific aspects of the user’s movement capability. For example, the“speed test” is a common test for quantification of movementspeed and accuracy. This test requires the user to move a cursora fixed distance into a fixed-sized target, and measures the timetaken to perform the movement (Fig. 2). The target randomlychanges location each time it is acquired, or after six seconds ifit is not acquired. The cursor trajectory is sampled at approxi-mately 10 Hz and saved to the server so that the cursor trajec-tories can be plotted if desired. Sixteen targets are presented foreach test.

Other tests include a “coordination test” that requires theuser to trace a figure eight and measures the tracing error, anda “finger speed test” that requires the user to click the mousebutton as many times as possible in ten seconds. When a forcefeedback joystick is used as the input device, a “strength test”is possible. Similar to manual muscle testing, this test requiresthe user to hold the hand as still as possible within a targetwindow as the joystick applies 0.1-Hz sinusoidal forces thatalternate directions. The total distance moved is recorded asthe score.

2) Therapy Games:Therapy games challenge sensorymotor ability in an engaging context. For example, “BreakoutTherapy” is a modified version of the classic arcade game“Breakout!” (Fig. 2). In this game, the user controls a paddlein order to rebound a moving ball into a bank of targets. Thescore is the number of targets destroyed on three attempts.

When a force feedback joystick is used as the input device,the system can physically assist or resist the user in playing thetherapy games. For example, in Breakout Therapy, if the user istoo weak to play the game, the force feedback joystick physi-cally assists in hand movement by predicting the trajectory ofthe ball after each rebound. The rest length of a virtual springis programmed such that the spring attracts the joystick handle(and thus the game paddle) to the location required to reboundthe ball. If the user is relatively coordinated, the joystick can


Fig. 2. Design of the software user interface.

resist movement by positioning the rest length away from therequired paddle location, thereby making the game more chal-lenging.

Note that the distinction between therapy games and statustests is artificial. Status tests when performed repetitively alsocomprise a therapeutic activity; conversely, performance ontherapy activities is also quantified. However, we find the dis-tinction useful because therapy games are in general designedto be more “arcade-like” and engaging, while status tests aresimpler and more amenable to quantification.

3) Progress Charts:Three types of progress charts providequantitative feedback of rehabilitation progress. The first chartkeeps track of system usage. This “To Do List” is displayedupon logging in and shows the user’s desired frequency of useof various activities, compared to the actual frequency of use,on a weekly time scale (Fig. 2). The desired frequency can beprescribed by the user or by a monitoring caregiver using the“therapist page” described later. When the actual frequency foran activity exceeds the desired frequency, the system places en-couraging feedback on the “To Do List” by writing “Good Job!”next to the activity. The activities listed in the “To Do List” arealso hyperlinks, providing a convenient means to access the pre-scribed rehabilitation plan.

The second type of chart provides performance feedbackimmediately upon completion of an activity. This “immediateprogress report” shows the score for the activity along withthree references for comparison: a customizable target score,the average past performance on the activity, and the previousscore achieved on the activity.

A third type of chart, the “progress overview,” displays agraphical history of the user’s scores on a particular activity

(Fig. 2). The scores can be displayed either as a function of timeor as a function of the number of times the activity has beenperformed. The progress overview also shows the customizabletarget score.

4) Therapist Page:The therapist page provides three impor-tant functions. Initially, it provides a means for adding new useraccounts. Subsequently, it provides a means for designing andadjusting rehabilitation programs by allowing desired activityusage profiles to be set. It also provides a means for a super-vising therapist to monitor rehabilitation progress for a groupof patients, by allowing the therapist to view individual progresscharts.

5) Navigating the Interface:The interface is designed suchthat users control the input device with their impaired arm fortherapy. However, some users have such poor control over theirimpaired arm that navigating the interface between activities isdifficult. To minimize this difficulty, all menu items are large.Also, for users who can move their arm but cannot control but-tons on the input device, the keyboard can be reprogrammedusing Microsoft’s Accessibility Options so that menu items areselected by depressing a customized key with their contralateralhand. For users who cannot move their arm adequately to con-trol the cursor, menu items can be navigated using the tab key,or by controlling the cursor using arrow keys with the contralat-eral hand.

C. Software Design

The Java Therapy system is implemented using severalprogramming languages including Java, Hypertext MarkupLanguage (HTML), Active Server Pages (ASP), ActiveX,


Fig. 3. Overview of client-side processing used by Java Therapy. Java appletsthat encode status tests, therapy games, and progress charts are downloaded ontothe user’s computer and executed locally. The applets and input device (e.g.,joystick) communicate using Java Script and Active Server Pages, and the appletwrites data to the remote server computer.

PERL, and CGI. This section reviews key features of thesoftware structure.

1) Use of Java:Java applets were used to implement theprogress charts, status tests, and therapy activities. Java waschosen as the core programming language for three main rea-sons. First, when a user visits a web site, a copy of the Javaapplet is downloaded onto the user’s computer for local exe-cution (Fig. 3). This client side processing reduces the burdenon the server and allows more reliable control of force feed-back. Second, when changes to applets are required, they canbe applied at the server computer since the client receives afresh copy of the applet each time the user logs into the website. Thus, new versions of the therapy programs are automati-cally installed each time a user accesses the therapy web page.This is beneficial not only for facilitating rapid modificationsof the system, but also provides a means for personalizingtherapy plans. A third advantage is the platform independenceof Java. Using any Java-enabled Web browser, users on a va-riety of computing platforms, with any input device, can accesstherapy.

2) Communicating With the Joystick: ActiveX Control andJava Scripting: An ActiveX controller is a marketing namefor the set of technologies and services based on the compo-nent object model (COM). Any device that supports this COMservice can communicate with another device that also sup-ports the COM technology. For Java Therapy, an ActiveX con-troller (FEELtheWEB software developed by Immersion Cor-poration) implements forces on the joystick and take commands

from over the Internet. The ActiveX controller must be installedon the user’s computer prior to use of the system. The Website then commands forces on the joystick by calling JavaScriptfunctions supported by the embedded ActiveX controller fromHTML. The JavaScript functions are called from the Java ap-plet using the Netscape Live Connect package and by using theMAYSCRIPT tag in the applet tag.

3) Database: Active Server Pages and PERL:An ASP doc-ument is like an HTML document that supports server-side aswell as client-side scripting. Since a Java applet is a client-sideentity, ASP pages can be used to write or process the data col-lected from the applet onto the server. When the Java applet isready to transmit its data, the data is encoded and posted to anASP page, which in turn takes the data and writes it to a file onthe computer. ASP pages are used to write cursor trajectories(sampled at 10 Hz) achieved during status tests. The PERL pro-gramming language is used to manage a database implementedin Microsoft Access that contains information on the user’s pro-file and account, and tracks the usage of and scores achievedwith the system.

4) Server: The Java Therapy system is served using a500-MHz Intel Pentium III computer with a ten millionbits-per-second Internet connection, housed in the Biomecha-tronics Laboratory at the University of California at Irvine.The server operating system is Microsoft Windows NT, andMicrosoft Internet Information Server for World Wide Web andFTP service. As previously described, the server stores datafrom Java Therapy activity in a text file format through ASPpages as well as in a Microsoft Access database.

III. EXAMPLE DATA

This section presents data from a chronic stroke subject thatshow how the system can be used to direct a therapy program,robotically assist in movement, and track improvements inmovement ability. The subject was 54 years old and had a leftcerebral infarction of the basal ganglia, frontal operculum,and corona radiata 15 months previously. He exhibited severearm movement impairment, scoring a 1 out of 7 on the Che-doke–McMaster Upper Extremity Scale [26], and a 3 out of 7on the Functional Test for the Hemiparetic Upper Extremity[27], both of which correspond roughly to being able to lift thearm from the side to the lap but not more than a few inchesabove the lap. The subject possessed no hand grasp or forearmsupination ability and initially required assistance from hiscaregiver in attaching his hand to the system. With practiceover several weeks, he was able to attach his paretic hand to thejoystick using his contralateral hand without assistance fromhis caregiver. The subject used a 266-MHz Pentium I computerwith a 56-K modem to access the system.

A customized exercise program was designed that includeda weekly, recommended frequency of 20 trials of the speed,coordination, and strength tests, and 10 min of Breakout AssistTherapy. The subject logged in to the system 36 times overa twelve-week period. He met his weekly recommended fre-quency for the speed test and Breakout Assist Therapy, and


Fig. 4. The subject reduced the time required to complete the speed test byapproximately 40% over the course of 12 weeks. Each speed test required 16targeted movements. The dashed line shows the approximate performance of anunimpaired arm.

(a) (b)

Fig. 5. Cursor trajectories during the first (left) and twelfth (right) week of JavaTherapy. The squares show the positions and sizes of the targets. The subjectattempted to move from the center target to each perimeter target and back.

performed approximately 75% and 50% of the program forthe coordination and strength tests. He executed the speed testmost often (177 times), averaging seven speed tests for eachlogin session during which he played the speed game. Sinceeach speed test required 16 sequential targets per test, the sub-ject performed 2832 targeted movements over the twelve-weekperiod.

As a test of the ability of the system to robotically assistin movement, in one supervised session the subject alternatedplaying Breakout ten times with and without assistance fromthe joystick. The subject destroyed on average eight (5 S.D.)blocks with the robotic assistance, and one (5 S.D.), indicatingthe ability of the joystick to assist even a severely impaired limb.The subject expressed a strong preference for the Breakout As-sist game, as without the assistance he essentially could not playthe game.

As an example of tracking improvements in movementability with the system, scores from the speed test are pre-sented in Fig. 4. Over the 12-week experiment period, thesubject improved his mean movement speed on the speed testby approximately 40%, with the mean scores on the first andlast ten tests being significantly different (t-test, 0.001). Atthe beginning of therapy, he exhibited poor control over handmovement trajectories, particularly to targets on the right sideof the screen [Fig. 5(a)]. With repeated practice he was able tomove more directly, although not perfectly, toward each target[Fig. 5(b)].

Fig. 6. Analysis of within-session learning on the speed test. Each thin linecorresponds to a different login session, in which the speed test was performedsequentially on average seven times. The thick line is the ensemble averageacross login sessions.

As an example of how the system might assist in gaining in-sight into the nature of motor recovery after stroke, the speedtest data were analyzed for within-session learning. As previ-ously noted, after logging in and starting a therapy session, thesubject performed the speed test seven consecutive times on av-erage. When the scores on these sequential speed tests wereensemble-averaged across therapy sessions, there was no evi-dence of within-session learning (Fig. 6). The overall perfor-mance improvements apparently accrued between sessions, ona time scale of days. This learning profile is consistent with thetemporal dynamics of strengthening or a similar process, ratherthan short-term motor learning.

The subject was evaluated in person by one of the investiga-tors at four-week intervals. The investigator noted that the sub-ject incorporated progressively less trunk motion in moving hisarm, consistent with observations from his caregiver (Table I).With practice, he also developed the ability to attach his handto the system without help from his caregiver, executing histherapy independently. The subject improved to a 2 out of 7on the Chedoke–McMaster Upper Extremity Scale (due to in-creased elbow flexion/extension ability), but did not improveon the Functional Test of the Upper Extremity. After comple-tion of the therapy program, the subject expressed strong ap-proval of the system, responding “Strongly Agree” (8 on aneight-point scale) to questions on a user satisfaction survey thatincluded “The Java Therapy exercise program is something Iwould continue to use if I had access to it”; “It was convenientto have access to the Java Therapy system online, as opposedto a clinic”; “My arm movement improved after participating inthe Java Therapy exercise program.” Comments from the sub-ject’s caregiver are shown in Table I, and provide a subjectivebut interesting perspective on use of the system.

IV. DISCUSSION ANDCONCLUSION

Java Therapy is a pragmatic system for guiding repetitivemovement practice. It allows users to organize, practice, andmonitor a range of therapeutic activities in an affordable, acces-sible, and readily modifiable fashion through its use of mass-manufactured input devices, existing Web infrastructure, and


TABLE ICOMMENTS PROVIDED BY THE SUBJECT’S PRIMARY CAREGIVER

Java applets. The data obtained from a chronic stroke subjectdemonstrate the ability of the system to organize a therapy pro-gram, engage a user in the program, and track movement re-covery.

A straightforward enhancement to the system would be toincorporate a low-cost camera for taking pictures of the userduring system use. Such a camera could allow a remote clini-cian to observe the user’s performance on an intermittent basisor in real-time via teleconferencing software, thereby providinginsight into how the user is interacting with the system and whatmotions (e.g., isolated arm versus whole body) he or she is prac-ticing. The clinician could then teleconsult with or email theuser, instructing him or her to focus on achieving specific, de-sired movement patterns.

A key goal of future research will be to refine and validate thelibrary of therapy and evaluation activities. Currently, the rela-tionship between particular activities, practice intensities, andmeaningful movement recovery remains unclear. For example,although the subject in the present study improved performanceon the speed test, the functional scale did not detect this im-provement. A reasonable working hypothesis is that users willexperience the greatest recovery in association with the move-ments that are practiced the most, and that increased practicewill result in greater recovery, within the constraints imposedby lesion type and extent. Using a joystick or mouse as inputdevice, it might be expected that individuals will improve in spe-cific functional activities that require fine shoulder/elbow coor-dination, such as computer mouse usage, handwriting, and cut-ting food.

Recovery of a broader range of functional activities will likelybe facilitated by development of other input devices that can ad-equately monitor and direct those activities. An important focusfor future research will be to develop low-cost sensor systemsand associated processing algorithms that can assess a diver-sity of functional movements using continuous, objective scales.Low-cost micromachined inertial sensors [28] and image iden-tification systems [29], [30] hold promise as building blocks.The wearable computer, video game, and virtual reality indus-tries are generating novel, low-cost, mass-manufactured, inputdevices that may also be useful for movement rehabilitation. As

new monitoring devices and exercises programs are developed,the Java Therapy approach can provide an “operating system”for evaluating those devices and exercise programs. Because itis highly accessible, it makes feasible the testing of large subjectpopulations, as well as quick and broad dissemination of exer-cise programs once they are validated.

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David J. Reinkensmeyer(S’93–M’93) received theB.S. degree in electrical engineering from the Mass-achusetts Institute of Technology, Cambridge, andthe M.S. and Ph.D. degrees in electrical engineeringfrom the University of California at Berkeley, in1988, 1991, and 1993, respectively.

He was an NIDRR Postdoctoral Fellow, thenan NIH-NRSA Postdoctoral Fellow, in the Sen-sory Motor Performance Program, RehabilitationInstitute of Chicago and Department of PhysicalMedicine and Rehabilitation, Northwestern Univer-

sity Medical School, Evanston, IL, from 1994 to 1997. He was a ResearchAssistant Professor in the Department of Physical Medicine and Rehabilitation,Northwestern University Medical School, from 1997 to 1998, and currentlyholds an adjunct appointment there. He joined the Department of Mechanicaland Aerospace Engineering and the Center for Biomedical Engineering at theUniversity of California, Irvine, as Assistant Professor in 1998. His researchinterests are medical mechatronics, robotics, biomechanics, motor control andlearning, and neurorehabilitation.

Dr. Reinkensmeyer received a Whitaker Biomedical Engineering ResearchGrant in 1998. He is a Member of the IEEE-EMB and Robotics and AutomationSocieties, the Society for Neuroscience, and the Rehabilitation Society of NorthAmerica (RESNA).

Clifton T. Pang received the B.S. degree in mechan-ical engineering from the California PolytechnicState University, San Luis Obispo, the M.S. degreein mechanical engineering from the University ofCalifornia, Irvine, in 1998 and 2001, respectively,and is currently working toward the M.S. degree inelectrical engineering at San Jose State University,San Jose, CA, focusing on digital signal processing.

He is currently a Software Engineer at KLA-Tencor, San Jose, CA.

Jeff A. Nessler received the B.S. degree in sportsmedicine from Pepperdine University, Malibu, CA,the M.S. degree in biomechanics from San DiegoState University, San Diego, CA, in 1997 and 2000,respectively, and is currently working toward theM.S./Ph.D. degree in mechanical engineering at theUniversity of California, Irvine.

His research interests include biomechatronics, re-habilitators, and motor control.

Christopher C. Painter received the B.S. degree inmechanical engineering from the University of Cali-fornia, San Diego, the M.S. degree in mechanical en-gineering from the University of California, Irvine, in1999 and 2000, respectively, and is currently workingtoward the Ph.D. degree in mechanical engineering atthe University of California, Irvine.

His research interests are MEMS-based inertialnavigation systems, particularly microgyroscopesand accelerometers.

web-based telerehabilitation for the upper extremity after stroke

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