Retraining and assessing hand movement after stroke using the MusicGlove: comparison with conventional hand therapy and isometric grip training
© Friedman et al.; licensee BioMed Central Ltd. 2014
Received: 2 June 2013
Accepted: 17 March 2014
Published: 30 April 2014
It is thought that therapy should be functional, be highly repetitive, and promote afferent input to best stimulate hand motor recovery after stroke, yet patients struggle to access such therapy. We developed the MusicGlove, an instrumented glove that requires the user to practice gripping-like movements and thumb-finger opposition to play a highly engaging, music-based, video game. The purpose of this study was to 1) compare the effect of training with MusicGlove to conventional hand therapy 2) determine if MusicGlove training was more effective than a matched form of isometric hand movement training; and 3) determine if MusicGlove game scores predict clinical outcomes.
12 chronic stroke survivors with moderate hemiparesis were randomly assigned to receive MusicGlove, isometric, and conventional hand therapy in a within-subjects design. Each subject participated in six one-hour treatment sessions three times per week for two weeks, for each training type, for a total of 18 treatment sessions. A blinded rater assessed hand impairment before and after each training type and at one-month follow-up including the Box and Blocks (B & B) test as the primary outcome measure. Subjects also completed the Intrinsic Motivation Inventory (IMI).
Subjects improved hand function related to grasping small objects more after MusicGlove compared to conventional training, as measured by the B & B score (improvement of 3.21±3.82 vs. -0.29±2.27 blocks; P=0.010) and the 9 Hole Peg test (improvement of 2.14±2.98 vs. -0.85±1.29 pegs/minute; P=0.005). There was no significant difference between training types in the broader assessment batteries of hand function. Subjects benefited less from isometric therapy than MusicGlove training, but the difference was not significant (P>0.09). Subjects sustained improvements in hand function at a one month follow-up, and found the MusicGlove more motivating than the other two therapies, as measured by the IMI. MusicGlove games scores correlated strongly with the B & B score.
These results support the hypothesis that hand therapy that is engaging, incorporates high numbers of repetitions of gripping and thumb-finger opposition movements, and promotes afferent input is a promising approach to improving an individual’s ability to manipulate small objects. The MusicGlove provides a simple way to access such therapy.
KeywordsStroke rehabilitation device Hand Music therapy Video game therapy Stroke assessment Outcome measures
Hand impairment is a common condition that contributes substantially to disability in the U.S. and around the world . In the case of stroke alone, it is estimated that approximately 80% of the 700,000 individuals who survive a stroke each year require hand therapy [2–4]. Other conditions that have a high incidence of hand impairment are hand and wrist trauma, high-level spinal cord injury, multiple sclerosis, traumatic brain injury, muscular dystrophies, and cerebral palsy. In all of these conditions the human motor system retains substantial capacity for plasticity, and thus intensive rehabilitation exercise reduces long-term hand impairment [5–7]. Unfortunately, there currently exist few validated technologies for at-home upper-extremity rehabilitation after a stroke. A recent systematic review of home-based upper extremity therapy analyzed only four studies, and only two of these included a self-guided intervention .
Therapy is limited because on-going rehabilitation exercise delivered one-on-one with a rehabilitation therapist is expensive. Gyms do not have appropriate equipment to facilitate practice of the fine motor skills needed to improve hand dexterity. Few devices are commercially available for at-home hand therapy and these are either expensive or not motivating. For example the HandMentor  and HandTutor  cost several thousand dollars, and the Amadeo (TyroMotion) is even more expensive. Virtual reality and computer gaming is promising for home-based rehabilitation because it can provide ecologically valid, intensive task specific training . Systematic reviews of virtual-reality based rehabilitation delivered in the clinic indicate that is effective for arm rehabilitation, but there are fewer trials on hand rehabilitation [11, 12]. Following written sheets of exercise prescribed by the therapist is therefore a fairly common low cost approach to hand therapy, but this approach often lacks in intensity, repetition, and motivational value—factors thought to be important for maximizing hand movement recovery [4–7, 13]. Without guidance and a motivating rehabilitation regimen, individuals cease practice of their affected hand and do not recover to their full potential [2, 3, 14, 15].
Participating in music is a promising avenue for therapy because it is motivating, challenging, sensory-rich, and repetitive . Further, participating in music after a stroke can induce plastic changes in the motor cortex as well as increase attention span, neuropsychological scores, cognitive functioning and well-being [17–24]. fMRI studies show that motor and auditory temporal processing are coupled during the act of listening, meaning the motor system is responsive to the auditory system [25–27].
Recognizing the potential benefits that music therapy provides, several devices for music-based therapy have been developed to focus on movement repetition and auditory feedback [16, 20]. Adamovich developed a virtual piano trainer to retrain finger dexterity after stroke using a haptic device (CyberGrasp) worn over a dataglove (CyberGlove) . Alten Muller and Schneider developed a customized electronic keyboard and drum pad designed to train gross and fine hand movement . Although these devices promote movement using music, they are not focused on training hand movements used in activities of daily living such as key-pinch grip and pincer grasp. Based on the specificity of learning hypothesis in motor behavior, which holds that motor learning is most effective when practice sessions include movement conditions that closely resemble those required during performance of the task [29–31], training functional movements may be more beneficial to regaining motor function.
Objectively measuring hand use during therapy can be beneficial in providing effective rehabilitation. Quantitative feedback about movement performance can improve recovery of motor function in people with stroke . It also enables users to track improvements in hand use, and provides an objective, unbiased, account of a patient’s movement practice.
We previously conducted a usability study at the University of California, Irvine with 10 participants with chronic stroke. We found that the MusicGlove can be donned and used by people with severe hand impairment quantified by a Box and Block score of 7 (this test measures the number of blocks that subjects transport in a minute and a normal score is about 60) . Further, the MusicGlove-based assessments of hand function were correlated with standard clinical evaluations (i.e. Box and Block score), suggesting the device provides self-measurable, quantitative feedback to users, clinicians, and caregivers relevant to rehabilitation progress. We also found that the addition of music to hand movement practice in a single training session significantly improved both objective measures of hand motor performance during training and self-ratings of motivation for training. In a questionnaire, the majority of participants stated that the device was a motivating tool for therapy, and that they would like to continue using it for rehabilitation.
7 males, 5 females
57 +/- 30.5 SD, range 19–80
Months post stroke
34.6 +/- 32.5 SD, range 8–63
Side of Hemiparesis
4 left, 8 right
Type of stroke
The MusicGlove was described in the Introduction section and further details can be found in . To study the effect of isometric training with the hand, we developed the IsoTrainer, an isometric version of the MusicGlove device (Figure 2, left). To use the device, the person grips force sensors (Flexiforce) located on two neoprene covered acrylic boards located on opposing sides. When the user squeezes both the sensor on the thumb and one of the other respective sensors with digits 2–5 with roughly 10 N of force, an event is sent to a custom-made USB controller that transmits HID USB commands to the same Frets-on-Fire-like game used with the MusicGlove. A 360 degree rotating base accommodates multiple hand orientations.
Assignment and intervention
We compared three types of motor hand therapies consisting of training with the MusicGlove (Figure 2, left), IsoTrainer (Figure 2, middle) and conventional tabletop exercises (control) (Figure 2, right). The duration of training was matched for each type of therapy. We used a within-subject study design where each subject participated in six one-hour treatment sessions, approximately three times per week for two weeks, for each training type, for a total of 18 one-hour treatment sessions. We then analyzed how much motor control improved after the six one hour sessions for each training type. All training sessions were supervised by the same trained physical therapist who assisted the subjects in completing the training.
Subjects were randomly assigned to groups that experienced the MusicGlove, IsoTrainer, and control training in different orders. To ensure a match in impairment severity between groups, subjects were first blocked by the B & B assessment (0–30, 30–60) and then randomized using a table generated by a statistician. The treating therapists and subjects were blinded to group assignment until each subject was consented and enrolled in the study.
During the IsoTrainer intervention, participants were fitted to the device and performed the same Speed and Dexterity assessments before and after each training session. They completed the number of songs as with MusicGlove therapy in the same sequence. Performance scores (same as with MusicGlove therapy) were logged at the end of each song.
During the control intervention participants followed a series of conventional tabletop exercises (used at therapy clinics at the University of California in Irvine and Ohio University) consisting of passive range-of-motion stretches, active range-of-motion exercises, isometric strengthening exercises, and functional gripping practice for the hand. Time spent on each movement and number of total repetitions in a session was not controlled; only the total therapy time per session was controlled. If participants completed all prescribed exercises, they were asked to start again at the beginning until the 45 minute training session was complete. During passive stretches, subjects used their unaffected limb to move their affected hand. During active exercises, subjects practiced using their affected wrist and hand without the help of the unaffected hand. During isometric training, subjects performed active movements while using their unaffected hand to keep the affected hand in a static position. Subjects performed passive exercises for roughly 15-20% of the duration of each session. Functional gripping practice included touching the thumb to each fingertip, making a pincer grasp, power grasp, practicing thumb opposition, picking up coins, and picking up a pencil. Refer to the Additional file 1 entitled “Assessment Procedures” for more information on the administered table-top exercises.
Subjects were assessed at one and two weeks prior to the study, after the completion of the six treatment sessions, and at a one-month follow-up assessment. A single blinded evaluator who is an experienced occupational therapist performed all of the clinical assessments during all testing sessions. The primary outcome measure was the Box and Block Test (B & B), which measures how many blocks a subject can pick up and place in a box in 60 seconds. Other outcome measures included the following: 1.) the arm motor section of the Fugl-Meyer score (AMFM) , which measures motor function of the subjects’ hemiparetic arm; 2.) the Action Research Arm Test (ARAT) , which measures the time to complete various manipulation activities with the hands; 3.) the Wolf Motor Function test (WMFT) , which measures the performance of a list of functional activities with the arm; and 4.) the 9-hole peg test (NHPT) [4, 42–44], which measures how many pegs a subject can put in and remove from the holes in a fixed amount of time (reported in pegs/minute).
We measured hand grip strength using a hydraulic hand dynamometer (Jamar 5030 J1) and pinch strength between the thumb and digits 2–5 using a hydraulic pinch gauge (Jamar 7498–05). Participants were asked to sit upright with their shoulder at a neutral position, their elbow flexed to 90 degrees, and their forearm at a neural position. Participants were then asked to squeeze as hard as possible and then release. This procedure was repeated three times for each grip with both unaffected and affected hand. The average of the three measurements for each grip was reported.
We chose the Box and Blocks as the primary outcome measure because it quantifies an important skill – grasp and transport, is simple and quick to administer, and is more objective than FM, ARAT and WMFT because it depends less on the semi-subjective rating of the evaluator. Box and Blocks has excellent reliability as well, and is correlated with FM and ARAT . FM likely suffers from a ceiling effect for subjects with higher scores on this test, such as the ones we tested .
Following the six training sessions with each treatment type, participants completed selected items from the Intrinsic Motivation Inventory (IMI), a reliable and valid survey used to quantify motivation , and a user satisfaction questionnaire. For the IMI, we selected 13 of its 44 questions that were distributed into five subscales categorized as effort/importance, pressure/tension, perceived competence, value/usefulness, and interest/enjoyment. The selection of specific items from the IMI was suggested as a valid approach by the original developers of this scale ; subsets of IMI items analyzed together have been shown to be reliable .
We also used the results from the Dexterity and Speed tests described in Figure 3 as outcome measures. The names of these tests were chosen somewhat arbitrarily, but the Dexterity test was designed to evaluate how well subjects could respond to an unpredictable sequence of notes that continuously sped up. This test used only 3 notes in order to minimize the cognitive processing needed to complete the task. The Speed test in contrast was designed to test how well subjects could complete a predictable sequence of notes that sped up, and tested all finger-thumb pairs. Presenting the notes in a predictable way minimized the need for cognitive processing in this test; the core requirement was to move the fingers in an increasingly fast, but known, pattern.
A Student’s t-test showed no significant improvement between assessments one and two (administered pre-training); these assessments were averaged to establish a baseline. Outcome measures did not deviate significantly from normality (Kolmogorov-Smirnov test, P > .05). Therefore repeated measures analyses of variances (ANOVAs) were used with training type as the within-subjects repeated factor. A Greenhouse-Geisser adjustment was used when sphericity was violated (P < .05). One tailed, paired Student’s t-tests were then applied to evaluate whether there were differences in outcomes among the three training conditions, given our starting hypotheses that MusicGlove therapy would be more beneficial than IsoTrainer therapy and conventional therapy. The omnibus Friedman test and post-hoc Wilcoxon signed-rank test were used to compare user satisfaction survey results and the IMI for the three training types. A P value of < .05 was used as statistically significant, and a Bonferroni correction was applied to all post-hoc outcome measure tests and survey results to account for family-wise error (P = 0.05/3). To account for floor effects, 9HPT score was calculated as pegs per minute .
We measured how a matched duration of training (six 45 minute sessions) with the MusicGlove, IsoTrainer, or standard tabletop exercises (control) affected hand motor control in a within-subjects design.
Clinical outcome measures
Outcome measures overview a
Change in outcome measure pre- to post-training
Repeated measures ANOVA
P Between Training types
P pre-to-post training
MGL vs TTE
MGL vs ITR
ITR vs TTE
Box and Block Test (blocks/min)
28.4 ± 15.8
3.21 ± 3.82
-.29 ± 2.27
.083 ± 4.75
Arm Motor Fugl-Meyer (out of 66)
53.2 ± 7.29
.875 ± 3.19
.750 ± 2.14
1.83 ± 2.37
Wolf Motor Score
2.87 ± .290
.101 ± .141
.040 ± .079
.056 ± .127
Wolf Motor Time (seconds)
13.4 ± 11.5
-1.58 ± 3.13
-1.38 ± 3.05
-2.29 ± 3.84
Action Research Arm Test
38.1 ± 14.8
.875 ± 2.85
.167 ± 4.12
1.41 ± 3.44
9-Hole Peg (Pegs-minute)
7.10 ± 6.45
2.14 ± 2.98
-.855 ± 1.29
1.47 ± 4.55
Key pinch (kg force)
3.90 ± 1.85
0.417 ± 2.17
-.200 ± 3.41
.754 ± 1.06
Index pincer (kg force)
1.55 ± .880
.146 ± .463
.092 ± .672
.200 ± .347
Middle pincer (kg force)
1.68 ± 1.02
-.007 ± .686
.154 ± .668
.344 ± .712
Ring pincer (kg force)
1.09 ± .871
.039 ± .414
.183 ± .783
.311 ± .763
Little pincer (kg force)
.601 ± .641
-.108 ± .240
.100 ± .537
.175 ± .667
Figure 4, bottom, shows a plot of cumulative gains over the course of the study due to all three training types (i.e. over all 18 sessions) and illustrates that training benefits, which mostly occurred during the MusicGlove portion of training, persisted at the one month follow-up. There was no difference between training types in the assessment batteries that assessed a broader range of hand function – the Wolf Motor Function Test and Action Research Arm Test -- although each training type significantly or nearly significantly improved in the WMFT (Table 2).
An important issue in rehabilitation science and practice is to improve objectivity, sensitivity, and ease of measurement of clinical outcomes. We therefore studied how the overall game score for the MusicGlove correlated with the primary clinical outcome measure, the Box and Block score.
Relationship between MusicGlove game score and primary clinical outcome measure (Box and Block Score)
Relationship between MusicGlove test scores and Box & Block test score
Dexterity test day 1 start
Dexterity test day 1 end
Dexterity test day 6 start
Dexterity test day 6 start
Speed test day 1 start
Speed test day 1 end
Speed test day 6 start
Speed test day 6 end
Relationship between MusicGlove game score for the five grip types and Box and Block Score
Relationship of grip type and MusicGlove game performance
We developed the MusicGlove device to motivate people to complete a high number of functional gripping movements using a modified version of a popular music-based computer game. We tested this device against tabletop exercises guided by a rehabilitation therapist, and an isometric grip training protocol that used the same music-based game. First we will discuss the comparison of the MusicGlove with conventional therapy and then the comparison with the isometric training protocol. We will then discuss the use of the MusicGlove as an assessment tool.
Comparing outcomes of MusicGlove and conventional therapy
This study examined whether training with the MusicGlove improved hand motor function more than conventional tabletop exercises. We found that participants training with the MusicGlove significantly improved hand function related to grasping small objects (measured by B & B score and 9HPT) pre- to post-treatment, and to a greater extent when compared to the conventional exercise. Participants did not experience such gains on average after conventional therapy; this finding is not unique to this study and thus emphasizes the need to develop new ways to deliver effective rehabilitation for people with chronic stroke [50–52]. Improvement in fine gripping function with the MusicGlove lead to qualitative, self-reported functional gains such as fastening a bra, double-clicking a mouse, controlling chopsticks, tying shoes, washing dishes, using a remote control, and using the restroom independently. Further, the IMI survey and user satisfaction questionnaire indicated that participants overwhelmingly found training with the MusicGlove paradigm more interesting, useful, and motivating.
These findings are compatible with previous findings of effectiveness of robotic hand therapy (reviewed in ) and virtual reality-based therapy (reviewed in ): technology based rehabilitation is promising for improving motivation and quantification of therapy and its outcomes, and enables small amounts of functional benefit. The uniqueness of the MusicGlove is that it is a simple, safe, easy-to-use technology, compared, for example, to robotic devices, and it incorporates a time-proved, very popular, motivating game, compared, for example, to most custom-built virtual reality games for therapy.
There are several limitations of the study that should be considered. First, the sample size was small. Second, the within-subjects design precludes the possibility of definitively attributing the long term gains we measured at one month to the MusicGlove portion of the training protocol. Third, as stated above, the improvement in outcomes were small. To our knowledge, the minimally clinically important difference in the B & B score has not been assessed for chronic stroke subjects, but a 3 point improvement is clearly a small effect. The participants reported practical benefits to their home life due to the overall training experience, but at present, the results should be viewed as promising initial findings that must be improved upon. Fourth, we randomized participants to different orders of intervention to mitigate order effects but did not test for order effects due to the limited sample size. We did not account for possible cumulative effects of intervention when statistically analyzing outcome measures and we did not test retention after each intervention to gain more insight into learning effects. These are limitations that should be addressed in future, larger studies.
We hypothesize that the MusicGlove paradigm was more effective at improving performance of fine gripping because it motivated a large number of goal-directed functional movements of the thumb and fingers (a likelihood we nonetheless could not objectively evaluate in the present study because we did not count thumb or finger movements in the conventional therapy), and integrated sensory-rich visual and auditory feedback that motivated high effort levels, factors thought to be important for promoting recovery that have been emphasized in previous studies of virtual reality-based exercises . Future studies should examine whether training with the MusicGlove paradigm leads to larger functional gains per unit of therapy time and higher patient compliance than conventional therapy.
The movements practiced with the MusicGlove emphasized thumb mobility, although some movement of the fingers was necessary as well. The emphasis on thumb mobility may explain why we observed the greater improvements in the outcome measures that tested fine gripping tasks (i.e. B & B and NHPT), but did not observe greater improvements in the outcomes that measured a broader set of constructs related to hand and upper extremity function (ARAT and Wolf).
Comparing outcomes of MusicGlove and IsoTrainer therapy
A secondary aim was to test whether dynamic movement training associated with the MusicGlove would produce larger improvements in hand motor control compared to a matched form of isometric movement training with the IsoTrainer. We found that participants on average improved more with the MusicGlove than the IsoTrainer in the B & B test although this improvement only approached significance. There was also a trend towards increased grip strength for the IsoTrainer (Table 2), but this did not manifest as a gain in hand function. We speculate that functional gains for people with this level of starting hand impairment are more readily attained through training that incorporates movement of the thumb and fingers, perhaps because of the greater proprioceptive input such movement delivers, a possibility that should be studied in future research.
The user satisfaction questionnaire results given after subjects had experienced all three training types revealed that 11 out of 12 participants preferred the MusicGlove, and the IMI and survey results suggest that subjects found it to be a more effective, motivating, and useful tool for rehabilitation. Interestingly, participants experienced significant gripping gains pre- to post treatment and overwhelmingly preferred MusicGlove treatment even though participants played the same computer game and the same songs with both devices. This may be attributable to the MusicGlove being easier to use than the IsoTrainer, and incorporating dynamic movement in the training. Interestingly, the one participant (out of twelve) who preferred the IsoTrainer over the MusicGlove was also the most impaired subject in the study; the subject reported the IsoTrainer being easier to use.
Use of MusicGlove as an assessment tool
The MusicGlove game saves quantitative data about user performance to the computer after each song. We found that a simple overall measure of game play success, the percentage of total notes hit during the assessments, strongly correlated with the B & B score, a standard clinical assessment. Further, we found a linear correlation between B & B score for both the Dexterity test and Speed test for both percentage of total notes hit and percentage of notes hit for each grip type. This suggests that the MusicGlove paradigm can be used to provide feedback to both clinicians and users about their progress which is relevant to a variety of activities of daily living; i.e. those that require grip and transport of small objects. Notably, this feedback can be attained as a natural part of therapeutic use of the MusicGlove and does not require separate, complex assessment protocols.
MusicGlove scores were sensitive to within- and between-session gains for total percentage of notes hit and percentage of notes hit per grip type. On average, we found that participants significantly improved in the number of total notes hit and individual notes hit in both the Dexterity test and the Speed test from the start to the end of each session. Overall subjects improved a smaller amount between sessions. A larger within-session improvement may be attributable to short-term motor learning that produces an acute improvement in finger dexterity.
Scores from the MusicGlove game can also provide insight into hand motor impairment mechanisms, as some grips were consistently more impaired. Participants performed sequentially worse at the Speed test in frets 1–5 (fret 1 being a key pinch grip and fret 5 being a pincer grip with the little finger). Note that there may be an order effect due to the ordered sequence of notes on the Speed test. The order unlikely has a significant effect as the sequence is reversed for half of the test. This finding is supported by the grip strength test, where participants performed sequentially worse with pincer grips with middle, ring and little fingers.
The results of this study showed that after six 45 minute sessions, participants improved the ability to grip small objects more using the MusicGlove paradigm compared to conventional hand exercises, a result that may be attributable to the many repetitions of thumb and finger movements and higher engagement and motivation. When we removed some of the sensory input by making the music-based training isometric (i.e. we reduced the dynamic nature of the proprioceptive input), we found a trend towards decreased effectiveness, and a strong preference of participants toward the dynamic training. A simple measurement of success in the MusicGlove game, % of notes hit, was sensitive to changes within and between therapy sessions, and was clinically valid in the sense that it correlated strongly with the Box and Block score. This measure also provides insight into the increased level of impairment associated with movement of fingers 3–5. We expect that the% of notes hit measure will be valuable to users of the MusicGlove and their clinical caregivers to monitor their progress in improving hand function. Future research will test the feasibility of using this device in a domicile setting with individuals with subacute and chronic stroke, and other populations that exhibit hand impairment.
The word described was supported by R01 (NIH-R01HD062744-01) from the National Center for Medical Rehabilitation Research, the UC Irvine Institute for Clinical and Translational Science, and the Samueli Institute.
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