We thank the patients and healthcare staff of the First Affiliated Hospital of Zhejiang University School of Medicine for their support and cooperation throughout this study.

This study protocol received approval from the ethics committee of the First Affiliated Hospital of Zhejiang University (approval number IIT20210035C-R2), and informed consent was obtained from all participants. An experimental study employing quasi-randomization, single-blinding, and a control group was conducted to assess the feasibility and effectiveness of the program. 24 patients hospitalized in the rehabilitation medicine ward of the First Affiliated Hospital of Zhejiang University were invited to participate in this experiment. Inclusion criteria encompassed stroke patients confirmed by computed tomography (CT) or magnetic resonance imaging (MRI), aged 30-75 years, 6-24 weeks post-stroke, a Montreal Cognitive Rating Scale (MoCA) score &#60;2613, upper limb dysfunction14, unilateral hemiplegia, Brunnstrom stage 3-6 for sitting ability15, and cooperation for assessment and treatment. Exclusion criteria included a history of cognitive disorders, major organ dysfunction, visual or hearing impairment, abnormal mental behavior or antipsychotic drug use, severe spasticity (Ashworth scale 3-4)16, and shoulder subluxation or severe upper limb pain.
1. Study design
<ol>
	<li>Divide all the patients into the control group and the experimental group (12 in each group) according to the random number table method2. 
	NOTE: Before the experiment, the following assessments were completed by an experienced occupational therapist for all patients: The Montreal Cognitive Assessment (MoCA)13, Fugl-Meyer Assessment Upper Extremity Scale (FMA-UE)14, and Modified Barthel Index (MBI)17.</li>
	<li>Verify and confirm that patients in the experimental group underwent conventional drug therapy, including medications for antihypertensives, antidiabetics, antiplatelets, lipid-regulating agents, etc., as prescribed by their respective physicians.
	<ol>
		<li>Additionally, ensure that they received 30 min of routine occupational therapy training each day, comprising cognitive function training and upper limb function training. Furthermore, confirm that they dedicated 30 min daily to the digital occupational training system for a duration of 8 weeks. 
		NOTE: The term &#34;conventional drug therapy&#34; refers to standard medications prescribed for post-stroke care, and the specific medications may vary among patients and clinics.</li>
	</ol>
	</li>
	<li>Ensure that patients in the control group receive routine occupational therapy (OT) for 1 h each day, in conjunction with conventional drug therapy.</li>
	<li>Implement routine cognitive function training tailored to the types of patients&#39; cognitive impairment following the steps below: 
	NOTE: Both control and experimental group of patients receive these trainings.
	<ol>
		<li>For Memory dysfunction: Guide patients to engage in activities such as discussing pictures, reciting paragraphs, path memory exercises, and recalling life plots.</li>
		<li>For Attention dysfunction: Instruct patients to participate in eye tracking training, number classification exercises, and similar picture recognition training.</li>
		<li>For Dyscalculia: Request patients to perform simple addition and subtraction exercises involving numbers less than 50, along with activities like shopping and financial simulation training.</li>
		<li>For Visuospatial disturbance: Guide patients through activities such as stacking wood, solving jigsaw puzzles, drawing, and turning objects.</li>
		<li>For Executive dysfunction: Lead patients in activities like origami, hand-making, painting, watering flowers, and others.</li>
		<li>For Thinking and reasoning dysfunction: Guide patients in classifying items, arranging numbers, simulating supermarket shopping, progressing from general reasoning to specific reasoning.</li>
	</ol>
	</li>
	<li>Instruct patients to engage in conventional upper limb functional exercises, encompassing passive and dominant movements of each joint of the upper limb. This includes activities like roller training, upper limb extraction, throwing and catching the ball, and control training for shoulder, elbow, and wrist movements.
	<ol>
		<li>Additionally, include forearm pronation and supination, finger fine movements, and coordination flexibility training, such as using a pin board and screw screwing. 
		NOTE: Dressing and stripping training, self-help equipment application, and other exercises to enhance the ability of daily living activities should primarily focus on the affected side, with appropriate incorporation of the healthy side to assist in the training of the affected side. All experimental steps are conducted in the rehabilitation room of the ward. The mentioned training is carried out 5 days a week for a duration of 8 weeks.</li>
	</ol>
	</li>
</ol>
2. Training process of the digital occupational training system
NOTE: Only the experimental group receive these trainings.
<ol>
	<li>Instruct the patient to stand or sit in front of the device (Figure 1) and adjust the display to an appropriate height and tilt angle, allowing easy access for the patient&#39;s hands to touch the screen.</li>
	<li>Create an individualized profile for each patient, including their full name, age, hospitalization identification number, diagnosis, and other relevant medical details.</li>
	<li>Select the appropriate training program based on the patient&#39;s cognitive impairment type and the remaining muscle strength of the upper extremities. Set parameters for each program, such as training duration, difficulty level, and left or right side (Figure 2).</li>
	<li>Explain and demonstrate the correct operation method for each program to ensure the patient fully comprehends the purpose of the training.</li>
	<li>Conduct Cognitive function training.
	<ol>
		<li>For patients with Memory dysfunction, follow the training process as mentioned below. 
		NOTE: If the patient has memory dysfunction, therapists can choose from the following training procedures: &#34;Rapid Matching Training,&#34; &#34;Memory Matrix Training,&#34; and &#34;Card Memory Training.&#34;
		<ol>
			<li>Rapid Matching Training: Click pictures on the screen and ask the patient to remember the previous picture. Then ask the patient to click on the Icon button to confirm whether the current picture matches the previous one.</li>
			<li>Memory Matrix Training: Click to make three bright squares flash at different locations on the screen matrix. Then, click to darken all squares and ask the patient to click on the bright squares.</li>
			<li>Card Memory Training: Click to display two pictures on the screen and then flip them over. Instruct the patient to find the target card that matches the one shown on the screen.</li>
		</ol>
		</li>
		<li>For patients with Attention dysfunction, conduct the following training process. 
		NOTE: For patients with attention dysfunction, select from the following training procedures: &#34;Reaction Ability Training,&#34; &#34;Color Matching Training,&#34; &#34;Whack-A-Mole Game,&#34; and &#34;Card Memory Training.&#34;
		<ol>
			<li>Reaction Ability Training: When a cake falls above the cartoon avatar, instruct the patient to quickly click on the catch button to prevent the cake from hitting the head.</li>
			<li>Color Matching Training: When the ball above the track is close to the center of the circle, guide the patient to click on the corresponding color to make the ball bounce, either two or four beats depending on the difficulty.</li>
			<li>Whack-A-Mole Game: Introduce a game where the bad guy crosses the land, or the gopher sticks its head out. Instruct the patient to click and hit the bad guy or the gopher to earn game points.</li>
			<li>Card Memory Training: Display card information, flip the card, and change its position. Ask the patient to find and click on the target card again according to the specified requirements.</li>
		</ol>
		</li>
		<li>For patients with Numeracy and judgment impairment, conduct the following training process. 
		NOTE: When the patient has numeracy and judgment impairment, therapists should choose programs such as &#34;Rock-Paper-Scissors,&#34; &#34;Arithmetic Reasoning Training,&#34; &#34;Sorting and Picking Training,&#34; and &#34;Fishing Game.&#34;
		<ol>
			<li>Rock-Paper-Scissors: Display a left-right hand gesture on the screen and ask the patient to make a quick judgment, clicking to determine whether the left-hand wins, the right-hand wins, or it&#39;s a tie.</li>
			<li>Arithmetic Reasoning Training: Instruct the patient to calculate the arithmetic problem on the screen and compare it to the number, selecting the greater than, less than, or equal button. Increase the difficulty of the arithmetic problem with the setting&#39;s difficulty level.</li>
			<li>Sorting and Picking Training: Ask the patient to pick and click on the appropriate type and quantity of items from the list according to the requirements in the upper left corner.</li>
			<li>Fishing Game: Following the prompt information, instruct the patient to click on the screen to catch a specific type and number of fish to earn game scores.</li>
		</ol>
		</li>
		<li>For patients with Visuospatial disturbance, conduct the following training sessions. 
		NOTE: The following training procedures are suitable for patients with visuospatial disturbance: &#34;Unilateral Neglect Training,&#34; &#34;Jigsaw Puzzle Training,&#34; &#34;Picture Combination Training.&#34;
		<ol>
			<li>Unilateral Neglect Training: Click according to the video prompts to control the swimming red fish with the fingers and eat as many fish as possible.</li>
			<li>Jigsaw Puzzle Training: Click and put the broken pieces of the puzzle into the correct position so that they form a complete picture again.</li>
			<li>Picture Combination Training: Select appropriate pictures from various shapes and colors on the left and place them in the correct position on the right to combine and form a specific pattern.</li>
		</ol>
		</li>
		<li>For patients with Executive dysfunction, conduct the following training sessions. 
		NOTE: Patients with executive dysfunction can choose the &#34;Virtual Kitchen&#34; program. Patients can gradually complete the production process of &#34;scrambled tomato and egg&#34; virtually under the guidance of the system. Specific steps are as follows:
		<ol>
			<li>Prepare food materials: Instruct the patient to virtually (on screen) turn on the faucet, clean the tomatoes, cut the tomatoes into pieces, and place them on the plate. Then, put the eggs into the bowl and stir them.</li>
			<li>Cooking: Instruct the patients to fire up the stove, pour the cooking oil, pour the beaten eggs, and then add the tomatoes.</li>
			<li>Serve the dishes: After completion, guide the patient to turn off the heat and transfer the cooked dish onto the plate.</li>
		</ol>
		</li>
		<li>For patients with Thinking and reasoning dysfunction, conduct the following. 
		NOTE: If the patient has naming and conceptual difficulties, choose from &#34;Naming Training,&#34; &#34;Card Memory Exercise,&#34; and &#34;Object Differentiation Training.&#34;
		<ol>
			<li>Naming Training: Guide patients to find and click on the correct picture among multiple pictures based on the requirements of text information and sound, or choose and click on the correct name of the item according to the picture information prompts.</li>
			<li>Card Memory Exercise: Among the cards that appear on the screen, ask the patients to find and click the one that is the same as the one in the hand of the cartoon man in the upper right corner.</li>
			<li>Object Differentiation Training: Among several columns of shapes appearing on the screen, ask the patients to identify and click the one that is unique and different from the others.</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>Conduct Upper limb functional training.
	<ol>
		<li>Train the patients with Auxiliary exercises or one-handed exercises. 
		NOTE: If the affected limb is unable to complete the training alone, have the healthy hand hold the affected limb and complete auxiliary training. Once the affected limb regains a certain level of muscle strength, one-handed training can be initiated. The following training procedures are suitable for auxiliary exercises or one-handed exercises: &#34;Drawing Exercise,&#34; &#34;Musical Journey,&#34; &#34;Walking The Maze.&#34;
		<ol>
			<li>Drawing Exercise: According to the path prompts appearing on the screen, instruct the patients to draw specific lines or outlines of the pattern. The system will automatically generate a beautiful picture. As the difficulty increases, consider allowing the path to disappear and ask the patient to outline the picture from memory.</li>
			<li>Musical Journey: Have the patient erase gray squares on the screen in sync with the rhythm of the music, transforming them into colorful squares. This provides an intensely pleasurable experience.</li>
			<li>Walking The Maze: Instruct the patient to hold onto the small ball in the maze and guide the ball through the maze to reach the endpoint where the diamond is located.</li>
		</ol>
		</li>
		<li>Train the patients with Two-handed coordination exercises. 
		NOTE: If the affected limb has good muscle strength, two-hand coordination training can be initiated. Choose procedures such as &#34;Balance Ball,&#34; &#34;Fish Feeding Game,&#34; &#34;Archery Practice,&#34; and &#34;Reaction Coordination Training.&#34;
		<ol>
			<li>Balance Ball: Have the patient place their left and right fists on both ends of the balance beam, which has a small blue ball on it. Instruct them to maintain balance and prevent the ball from rolling off either side.</li>
			<li>Fish Feeding Game: Instruct patients to hold down the feed with one hand and click on the small fish swimming on the screen with the other hand to complete the fish feeding task.</li>
			<li>Archery Practice: Guide the patient to place one hand on the bow and the other on the arrow, clicking and controlling the arrow so that it hits the bull&#39;s eye perfectly.</li>
			<li>Reaction Coordination Training: Let the right and left hands of the patients hold down the hammer and click to hit the yellow ball alternately, similar to the game of ping-pong, to train the patient&#39;s coordination and reaction ability. 
			NOTE: Upon the completion of training for each procedure, the instrument automatically provides an analysis of the training results, storing them in the patient&#39;s exclusive file. The therapist evaluates the patient&#39;s training effect by comparing the results each time (Figure 3 and Figure 4).</li>
		</ol>
		</li>
	</ol>
	</li>
	<li>As the patient&#39;s function recovers, ask the therapist to regularly recombine the training program, adjusting the difficulty and duration of the procedure based on the patient&#39;s performance. 
	NOTE: Throughout the training period, the therapist supervises the entire training process of the patient, patiently listens to the patient&#39;s needs, assists the patient when encountering difficulties, and offers praise and encouragement upon successful completion of training tasks.</li>
</ol>
3. Follow up procedures
<ol>
	<li>Following 8 weeks of treatment, conduct a reassessment of all patients using the MoCA, FMA-UE, and MBI. This reassessment is carried out by the same occupational therapist.</li>
	<li>Statistically analyze the collected data from the pre- and post-training assessments to determine the significance of the outcomes. 
	NOTE: Appropriate statistical methods were employed, depending on the normality of the data distribution, to assess the impact of the digital occupational training system on the recovery of cognitive and motor functions.</li>
</ol>

Enhancing Stroke Rehabilitation with Virtual Reality-Based Occupational Training

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The authors have stated that there are no conflicts of interest or financial disclosures associated with this study.

A virtual reality rehabilitation system was implemented to support the recovery of stroke patients, utilizing the latest multi-touch screen technology to enhance training engagement, immersion, interactivity, and conceptualization. This system provides interactive upper limb motor control training that integrates vision, hearing, and touch. It also includes rehabilitation training modules targeting memory, attention, spatial perception, computing, hand-eye coordination, and virtual tasks, offering personalized cognitive training. Moreover, the digital rehabilitation enhances cognitive and upper limb recovery through enriched virtual activities of daily living (ADL) and cognitive training18,19.
The current approach to cognitive function rehabilitation post-stroke typically involves computer-assisted training and occupational therapy, sometimes supplemented by methods like hyperbaric oxygen therapy and transcranial electrical stimulation20. In contrast, the VR-based training system described here offers high-intensity, repetitive, and highly reproducible motor training21. The system intelligently adjusts game difficulty levels based on a patient's rehabilitation progress, tailoring tasks for high-intensity training. Additionally, virtual reality games are accessible at any time and place, enabling patients to engage in rehabilitation training more frequently and achieve a higher number of repetitions.
Compared to existing VR devices, the digital occupational training system stands out as a more personalized and flexible rehabilitation option, concentrating patients' efforts and attention for improved outcomes. Active participation by patients is crucial during neuroplasticity, motor learning, and rehabilitation. Combining rehab therapy with patients' voluntary exercise has been found to promote the recovery of lost motor capabilities22,23. This virtual rehabilitation offers advantages in motivation, safety, and customization, while also allowing for the monitoring and analysis of users' performance during training. Evaluations using a 7-point Likert-type scale have shown positive results, indicating improved acceptability, expectation effectiveness, satisfactoriness, and stability of the VR system24. Based on feedback from occupational therapists and individuals with cognitive impairment, the results suggest that this training system is both feasible and usable.
The virtual reality device can increase task repetitions (intensity) by enhancing enjoyment to encourage engagement in specific tasks. In comparison to existing VR devices, the digital occupational training system offers a more diverse range of cognitive and activities of daily living (ADL) training games. Low-cost virtual rehabilitation systems can serve as supplements to conventional rehabilitation, requiring reduced direct supervision. The utilization of motion sensors alongside VR systems allows rehabilitation professionals to digitally assess and track patients' functions25. Rehabilitation based on a digital training system is a promising tool that enables patients to actively participate in rehabilitation plans and achieve better recovery of motor functions.
However, there are lingering questions, such as identifying the primary beneficiaries of virtual reality rehabilitation, assessing the impact of immersive vs. non-immersive experiences, and determining the most effective feedback mechanisms26. Virtual reality can also be integrated into new therapeutic modalities, such as brain-computer interfaces and noninvasive brain stimulation, to enhance neuroplasticity and improve recovery outcomes27. The study faced limitations, including challenges related to gesture recognition, the need for precise motion angle and timing adjustments based on patients' motor capabilities, and the requirement for careful implementation of threshold limits6. Additionally, the relatively small sample size restricts the generalizability of the findings.
In conclusion, cognitive function training through a digital rehabilitation system significantly improves cognition, upper limb motor function, and ADL capabilities in stroke patients. This approach holds substantial potential for clinical rehabilitation and could be expanded to benefit more stroke rehabilitation centers in the future. Furthermore, the versatility of this method allows its application in various rehabilitation fields, including trauma recovery and the treatment of neurodegenerative diseases.

There is a high incidence, mortality, disability rate, and recurrence associated with stroke, or cerebrovascular accident1. Globally, stroke has surpassed tumors and heart disease to become the second leading cause of death, and it is the primary cause in China2. The incidence and social burden of stroke are expected to increase significantly in the coming years as the population ages. Survivors of stroke may continue to experience sensory, motor, cognitive, and psychological impairments3. The effects of a stroke can include paralysis of one side of the body, including the face, arms, and legs, a condition known as hemiplegia. This is the most common sequel to stroke and significantly impacts people's quality of life4.
Stroke poses a significant threat to people's health. Due to brain tissue damage, stroke and hemiplegia can result in hand dysfunction, hindering patients' activities of daily living (ADLs) and diminishing their quality of life5. Decreased upper limb function, especially of the hands as the distal body part, presents the most significant challenge in upper limb recovery6. Therefore, functional rehabilitation is crucial. Additionally, 20%-80% of stroke patients experience cognitive impairment, leading to deficits in attention, memory, language, and executive abilities7.
Currently, the clinical rehabilitation of upper limb hemiplegia primarily relies on comprehensive upper limb training and various occupational therapies (e.g., mirror box treatment8, suspension9, functional electrical stimulation10, among others). Recently, virtual reality and interactive video games have emerged as alternative rehabilitation methods. These interventions can facilitate high-capacity practice and reduce demands on therapists' time11. Virtual reality systems have rapidly evolved into new commercial devices that can be utilized to enhance cognitive and upper limb motor function in stroke survivors12. Despite these advancements, there are still unexplored avenues in this field.
Therefore, this study aims to investigate the effects of upper limb rehabilitation training combined with conventional upper limb rehabilitation on cognitive and upper limb motor function in stroke patients during the recovery period of hemiparesis, typically spanning the initial 6-24 weeks after the incident stroke. Additionally, we will examine its impact on daily life abilities. This research seeks to provide valuable evidence for the clinical application of robotic interventions.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>FlexTable digital occupational training system</td>
			<td>Guangzhou Zhanghe Intelligent Technology Co., Ltd.</td>
			<td>Observation on the rehabilitation effect of digital OT cognitive function training on stroke patients with decreased attention function</td>
			<td>FlexTable digital operation training system uses the latest multi-touch screen technology, virtual reality and human-computer interaction technology, integrates a variety of training methods, and provides digital advanced brain function and hand-eye coordination training</td>
		</tr>
		<tr>
			<td>SPSS 25.0</td>
			<td>IBM</td>
			<td></td>
			<td>https://www.ibm.com/support/pages/downloading-ibm-spss-statistics-25</td>
		</tr>
	</tbody>
</table>

cognitive function and upper limb rehabilitation training post-stroke using a digital occupational training system

Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the potential to meet these demands by providing engaging and motivating therapy options. The digital occupational training system is a VR application that utilizes cutting-edge technologies, including multi-touch screens, virtual reality, and human-computer interaction, to offer diverse training techniques for advanced cognitive capacity and hand-eye coordination abilities. The objective of this study was to assess the effectiveness of this program in enhancing cognitive function and upper extremity rehabilitation in stroke patients. The training and assessment consist of five cognitive modules covering perception, attention, memory, logical reasoning, and calculation, along with hand-eye coordination training. This research indicates that after eight weeks of training, the digital occupational training system can significantly improve cognitive function, daily living skills, attention, and self-care abilities in stroke patients. This software can be employed as a time-saving and clinically effective rehabilitation aid to complement traditional one-on-one occupational therapy sessions. In summary, the digital occupational training system shows promise and offers potential financial benefits as a tool to support the functional recovery of stroke patients.

In this study, 24 patients were enrolled presenting with upper limb dysfunction combined with various types of cognitive impairment following a stroke. The observed types of cognitive impairment included Amnesia, Agnosia, Executive Dysfunction, Attentional Impairments, among others. No statistically significant differences were found between the two groups in terms of sex, age, duration of disease, and type of stroke (P &#62; 0.05), as detailed in Table 1. The experimental group, which underwent upper limb rehabilitation using the digital occupational training system, exhibited greater improvements in FMA-UE14, MoCA13, and MBI17 compared to conventional therapy (Table 2).
Following the training period, the experimental group demonstrated a significant improvement in MoCA scores (P &#60; 0.05), while the control group did not show significant differences (P &#62; 0.05). Moreover, the improvement in the experimental group was more pronounced than in the control group (P &#60; 0.05) (Table 2). Regarding FMA upper limb scores, the experimental group showed significant improvement after 8 weeks of training (P &#60; 0.05), with a notable difference in improvement compared to the control group (P &#60; 0.05) (Table 2). Concerning BI scores, both groups exhibited significant improvements compared to before the intervention (P &#60; 0.05), and the improvement in the experimental group was significantly different from that in the control group (P &#60; 0.05) (Table 2). These findings underscore the effectiveness of the digital occupational training system in enhancing patients&#39; cognitive and upper limb abilities, surpassing traditional rehabilitation therapy in cognitive improvements.
Statistical analyses were conducted using a statistical software (see Table of Materials), with the significance level set at a two-tailed P &#60; 0.05. Parametric analysis, assuming data normality and homogeneity of variance, employed the independent samples t-test to compare differences between groups in scale scores.
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/65994/65994fig01.jpg" /> 
Figure 1: Digital Occupational Training System. The system&#39;s screen is positioned at an ergonomically suitable height and angle for stroke patients in a seated or standing position, promoting interactive engagement for rehabilitation exercises. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65994/65994fig01large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/65994/65994fig02.jpg" /> 
Figure 2: Game content and application of cognitive-based upper limb VR scheme. This figure graphically illustrates various tasks within the game, each meticulously designed to target specific cognitive and motor skills. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65994/65994fig02large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/65994/65994fig03.jpg" /> 
Figure 3: Analysis of archery game training results - the number of rings per target hit. This figure provides a statistical breakdown of participants&#39; performances within the archery game, visualizing the number of rings hit per target across multiple sessions. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65994/65994fig03large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/65994/65994fig04.jpg" /> 
Figure 4: Analysis of archery game training results map of active areas. The color gradients represent areas of high and low activity, providing insight into the accuracy and focal points of participants&#39; attempts, thus serving as a visual tool to assess motor control and coordination throughout the training. <a href="https://www-jove-com.remotexs.ntu.edu.sg/files/ftp_upload/65994/65994fig04large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td colspan="2" rowspan="2">Group</td>
			<td rowspan="2">n</td>
			<td colspan="2">Sex (n)</td>
			<td rowspan="2">Age (x&#177;s, y )</td>
			<td rowspan="2">Course of the disease (x&#177;s, d)</td>
			<td colspan="3">Type of stroke (n)</td>
			<td colspan="2">Hemiplegic side (n)</td>
		</tr>
		<tr>
			<td>Male</td>
			<td>Female</td>
			<td>Ischemic</td>
			<td colspan="2">Hemorrhagic</td>
			<td>Left</td>
			<td>Right</td>
		</tr>
		<tr>
			<td colspan="2">Control group (n = 12)</td>
			<td>12</td>
			<td>6</td>
			<td>6</td>
			<td>50.50 &#177; 5.50</td>
			<td>37.08 &#177; 11.48</td>
			<td>7</td>
			<td colspan="2">5</td>
			<td>7</td>
			<td>5</td>
		</tr>
		<tr>
			<td colspan="2">Experimental group (n = 12)</td>
			<td>12</td>
			<td>7</td>
			<td>5</td>
			<td>50.42 &#177; 5.52&#160;</td>
			<td>36.0 &#177; 10.86</td>
			<td>8</td>
			<td colspan="2">4</td>
			<td>6</td>
			<td>6</td>
		</tr>
		<tr>
			<td colspan="2">P</td>
			<td></td>
			<td colspan="2">&#62;0.05</td>
			<td>&#62;0.05</td>
			<td>&#62;0.05</td>
			<td colspan="3">&#62;0.05</td>
			<td colspan="2">&#62;0.05</td>
		</tr>
	</tbody>
</table>
Table 1. Baseline characteristics between the two groups. It presents a comprehensive comparison of baseline characteristics between the control and experimental groups. This includes demographic and clinical data, ensuring comparability between the groups and verifying the randomization process, hence confirming the robustness of the subsequent analysis.
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Group</td>
			<td></td>
			<td>MoCA</td>
			<td>FMA-UE</td>
			<td>MBI</td>
		</tr>
		<tr>
			<td>Control group (n = 12)</td>
			<td>Per-treatment</td>
			<td>18.25 &#177; 2.42</td>
			<td>31.83 &#177; 6.26</td>
			<td>57.42 &#177; 7.37</td>
		</tr>
		<tr>
			<td></td>
			<td>Post-treatment</td>
			<td>19.0 &#177; 3.16</td>
			<td>&#160;35.58 &#177; 5.04</td>
			<td>64.33 &#177; 6.51 *</td>
		</tr>
		<tr>
			<td>Experimental group (n = 12)</td>
			<td>Per-treatment</td>
			<td>18.33 &#177; 2.34</td>
			<td>32.42 &#177; 5.84</td>
			<td>57.33 &#177; 9.50</td>
		</tr>
		<tr>
			<td></td>
			<td>Post-treatment</td>
			<td>22.00 &#177; 2.92 **#</td>
			<td>40.67 &#177; 6.72**#</td>
			<td>71.42 &#177; 9.63 **#</td>
		</tr>
		<tr>
			<td colspan="5">*P &#60; 0.05, compared to pre-treatment; #P &#60; 0.05, compared to the control group</td>
		</tr>
	</tbody>
</table>
Table 2. Comparison of MoCA, FMA-UE, and MBI scores between two groups before and after training (x &#177; s). *P &#60; 0.05, compared to pre-treatment. #P &#60; 0.05, compared to the control group. The statistically significant values are highlighted, elucidating the impact of the VR-based training regime on cognitive and motor functions and showcasing the relevant improvements in participants&#39; capabilities post-training.

Watch this Scientific Journal Video about Cognitive Function and Upper Limb Rehabilitation Training Post-Stroke Using a Digital Occupational Training System at JoVE.com

Author Spotlight: Rehabilitation of Stroke Patients With a Digital Occupational Training System

The current protocol outlines how the VR-based digital occupational training system enhances the rehabilitation of patients with cognitive impairment and upper limb dysfunction following a stroke.

Cognitive Function and Upper Limb Rehabilitation Training Post-Stroke Using a Digital Occupational Training System

Stroke rehabilitation often requires frequent and intensive therapy to improve functional recovery. Virtual reality (VR) technology has shown the ...

cognitive-function-upper-limb-rehabilitation-training-post-stroke

Nanyang Technological University

Research

JoVE Journal

Medicine

986 Views.  Wenzhou Medical University. The current protocol outlines how the VR-based digital occupational training system enhances the rehabilitation of patients with cognitive impairment and upper limb dysfunction following a stroke.

Video: Author Spotlight: Rehabilitation of Stroke Patients With a Digital Occupational Training System

An Investigation of the Effects of Sports-related Concussion in Youth Using Functional Magnetic Resonance Imaging and the Head Impact Telemetry System

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth involved in organized sports such as competitive hockey are nearly six times more likely to suffer a severe concussion compared to children involved in other leisure physical activities2. While the most common cognitive sequelae of mTBI appear similar for children and adults, the recovery profile and breadth of consequences in children remains largely unknown2, as does the influence of pre-injury characteristics (e.g. gender) and injury details (e.g. magnitude and direction of impact) on long-term outcomes. Competitive sports, such as hockey, allow the rare opportunity to utilize a pre-post design to obtain pre-injury data before concussion occurs on youth characteristics and functioning and to relate this to outcome following injury. Our primary goals are to refine pediatric concussion diagnosis and management based on research evidence that is specific to children and youth. To do this we use new, multi-modal and integrative approaches that will:
 1.Evaluate the immediate effects of head trauma in youth 
2.Monitor the resolution of post-concussion symptoms (PCS) and cognitive performance during recovery 
3.Utilize new methods to verify brain injury and recovery
To achieve our goals, we have implemented the Head Impact Telemetry (HIT) System. (Simbex; Lebanon, NH, USA). This system equips commercially available Easton S9 hockey helmets (Easton-Bell Sports; Van Nuys, CA, USA) with single-axis accelerometers designed to measure real-time head accelerations during contact sport participation 3 - 5. By using telemetric technology, the magnitude of acceleration and location of all head impacts during sport participation can be objectively detected and recorded. We also use functional magnetic resonance imaging (fMRI) to localize and assess changes in neural activity specifically in the medial temporal and frontal lobes during the performance of cognitive tasks, since those are the cerebral regions most sensitive to concussive head injury 6. Finally, we are acquiring structural imaging data sensitive to damage in brain white matter.

This article provides an overview of a multi-modal approach to mild traumatic brain injury diagnosis and recovery in youth. This approach combines neuropsychological testing with functional magnetic resonance imaging and the Head Impact Telemetry System to monitor the relationship between head impacts and brain activity during cognitive testing.

One of the most commonly reported injuries in children who participate in sports is concussion or mild traumatic brain injury (mTBI)1. Children and youth ...

A Murine Model of Muscle Training by Neuromuscular Electrical Stimulation

Neuromuscular electrical stimulation (NMES) is a common clinical modality that is widely used to restore1, maintain2 or enhance3-5 muscle functional capacity. Transcutaneous surface stimulation of skeletal muscle involves a current flow between a cathode and an anode, thereby inducing excitement of the motor unit and the surrounding muscle fibers. 
NMES is an attractive modality to evaluate skeletal muscle adaptive responses for several reasons. First, it provides a reproducible experimental model in which physiological adaptations, such as myofiber hypertophy and muscle strengthening6, angiogenesis7-9, growth factor secretion9-11, and muscle precursor cell activation12 are well documented. Such physiological responses may be carefully titrated using different parameters of stimulation (for Cochrane review, see 13). In addition, NMES recruits motor units non-selectively, and in a spatially fixed and temporally synchronous manner14, offering the advantage of exerting a treatment effect on all fibers, regardless of fiber type. Although there are specified contraindications to NMES in clinical populations, including peripheral venous disorders or malignancy, for example, NMES is safe and feasible, even for those who are ill and/or bedridden and for populations in which rigorous exercise may be challenging. 
Here, we demonstrate the protocol for adapting commercially available electrodes and performing a NMES protocol using a murine model. This animal model has the advantage of utilizing a clinically available device and providing instant feedback regarding positioning of the electrode to elicit the desired muscle contractile effect. For the purpose of this manuscript, we will describe the protocol for muscle stimulation of the anterior compartment muscles of a mouse hindlimb.

A murine model of neuromuscular electrical stimulation (NMES), a safe and inexpensive clinical modality, to the anterior compartment muscles is described. This model has the advantage of modifying a readily available clinical device for the purpose of eliciting targeted and specific muscle contractions in mice.

Neuromuscular electrical stimulation (NMES) is a common clinical modality that is widely used to restore1, maintain2 or enhance3-5 muscle functional ...

A Multi-Modal Approach to Assessing Recovery in Youth Athletes Following Concussion

Concussion is one of the most commonly reported injuries amongst children and youth involved in sport participation. Following a concussion, youth can experience a range of short and long term neurobehavioral symptoms (somatic, cognitive and emotional/behavioral) that can have a significant impact on one&#8217;s participation in daily activities and pursuits of interest (e.g., school, sports, work, family/social life, etc.). Despite this, there remains a paucity in clinically driven research aimed specifically at exploring concussion within the youth sport population, and more specifically, multi-modal approaches to measuring recovery. This article provides an overview of a novel and multi-modal approach to measuring recovery amongst youth athletes following concussion. The presented approach involves the use of both pre-injury/baseline testing and post-injury/follow-up testing to assess performance across a wide variety of domains (post-concussion symptoms, cognition, balance, strength, agility/motor skills and resting state heart rate variability). The goal of this research is to gain a more objective and accurate understanding of recovery following concussion in youth athletes (ages 10-18 years). Findings from this research can help to inform the development and use of improved approaches to concussion management and rehabilitation specific to the youth sport community.

This article provides an overview of a multi-modal approach to assessing recovery following concussion in youth athletes. The described protocol uses pre- and post-concussion assessment of performance across a wide variety of domains and can inform the development of improved concussion rehabilitation protocols specific to the youth sport community.

Concussion is one of the most commonly reported injuries amongst children and youth involved in sport participation. Following a concussion, youth can ...

Adapted Resistance Training Improves Strength in Eight Weeks in Individuals with Multiple Sclerosis

Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis (MS). It is known that resistance strength training (RST) can improve strength in individuals with MS, however; it remains unclear the duration of RST that is needed to make strength gains and how to adapt hip strengthening exercises for individuals of varying strength using only resistance bands. This paper describes the methodology to set up and implement an adapted resistance strength training program, using resistance bands, for individuals with MS. Directions for pre- and post-strength tests to evaluate efficacy of the strength-training program are included. Safety features and detailed instructions outline the weekly program content and progression. Current evidence is presented showing that significant strength gains can be made within 8 weeks of starting a RST program. Evidence is also presented showing that resistance strength training can be successfully adapted for individuals with MS of varying strength with little equipment.

Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis. Isolated muscle strengthening is a useful method to target specific weaknesses. This protocol describes a progressive resistance-training program using exercise bands to increase hip muscle strength.

Hip weakness is a common symptom affecting walking ability in people with multiple sclerosis (MS). It is known that resistance strength training (RST) can ...

A Method for Quantifying Upper Limb Performance in Daily Life Using Accelerometers

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. It has become important to measure a person's activities in daily life, and not just measure their capacity for activity in the structured environment of a clinic or laboratory. A wearable sensor that is now enabling measurement of daily movement is the accelerometer. Accelerometers are commercially-available devices resembling large wrist watches that can be worn throughout the day. Data from accelerometers can quantify how the limbs are engaged to perform activities in peoples' homes and communities. This report describes a methodology to collect accelerometry data and turn it into clinically-relevant information. First, data are collected by having the participant wear two accelerometers (one on each wrist) for 24 h or longer. The accelerometry data are then downloaded and processed to produce four different variables that describe key aspects of upper limb activity in daily life: hours of use, use ratio, magnitude ratio, and the bilateral magnitude. Density plots can be constructed that visually represent the data from the 24 h wearing period. The variables and their resultant density plots are highly consistent in neurologically-intact, community-dwelling adults. This striking consistency makes them a useful tool for determining if upper limb daily performance is different from normal. This methodology is appropriate for research studies investigating upper limb dysfunction and interventions designed to improve upper limb performance in daily life in people with stroke and other patient populations. Because of its relative simplicity, it may not be long before it is also incorporated in clinical neurorehabilitation practice.

This protocol describes a method to quantify upper limb performance in daily life using wrist-worn accelerometers.

A key reason for referral to rehabilitation services after stroke and other neurological conditions is to improve one's ability to function in daily life. ...

Autonomic Function Following Concussion in Youth Athletes: An Exploration of Heart Rate Variability Using 24-hour Recording Methodology

Participation in organized sports makes a significant contribution to youth development, but places youth at a higher risk for sustaining a concussion. To date, return-to-activity decision-making has been anchored in the monitoring of self-reported concussion symptoms and neurocognitive testing. However, multi-modal assessments that corroborate objective physiological measures with traditional subjective symptom reporting are needed and can be valuable. Heart rate variability (HRV) is a non-invasive physiological indicator of the autonomic nervous system, capturing the reciprocal interplay between the sympathetic and parasympathetic nervous systems. There is a dearth of literature exploring the effect of concussion on HRV in youth athletes, and developmental differences preclude the application of adult findings to a pediatric population. Further, the current state of HRV methodology has primarily included short-term (5-15 min) recordings, by using resting state or short-term physical exertion testing to elucidate changes following concussion. The novelty in utilizing a 24 h&#160;recording methodology is that it has the potential to capture natural variation in autonomic function, directly related to the activities a youth athlete performs on a regular basis. Within a prospective, longitudinal research setting, this novel approach to quantifying autonomic function can provide important information regarding the recovery trajectory, alongside traditional self-report symptom measures. Our objectives regarding a 24 h recording methodology were to (1) evaluate the physiological effects of a concussion in youth athletes, and (2) describe the trajectory of physiological change, while considering the resolution of self-reported post-concussion symptoms. To achieve these objectives, non-invasive sensor technology was implemented. The raw beat-to-beat time intervals captured can be transformed to derive time domain and frequency domain measures, which reflect an individual&#39;s ability to adapt and be flexible to their ever-changing environment. By using non-invasive heart rate technology, autonomic function can be quantified outside of a traditional controlled research setting.

We demonstrate a 24 h heart rate recording methodology to evaluate the influence of concussion across the recovery trajectory in youth athletes, within an ecologically valid context.

Participation in organized sports makes a significant contribution to youth development, but places youth at a higher risk for sustaining a concussion. To ...

Setup and Execution Of the Blindfolded Code Training Exercise

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to improve resident physician communication and leadership strategies in high-acuity situations. The blindfolded code training exercise removes visual stimuli from the team leader, forcing the team leader to effectively utilize closed-loop communication. The simple act of blindfolding the team leader creates a learning environment where the leader must utilize a conceptual framework and critical thinking strategies to organize the team and manage the resuscitation. An advantage to this teaching technique is that it does not require any special simulation equipment, making it a low-cost approach. The blindfolded code training exercise can be applied to the management of any critically ill patient where the primary objective is to focus on developing communication skills in acute resuscitations. The purpose of the description of the blindfolded code training exercise is to provide guidance on how to perform this innovative teaching technique to force effective closed-loop communication.

The blindfolded code training exercise, which blindfolds the team leader in a code resuscitation simulation, is an advanced teaching technique to improve closed-loop communication, organizational skills, and critical thinking.&#160;

Miscommunication is the most common cause of preventable patient harm in medicine. Currently, there is limited knowledge of innovative techniques to ...

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Here, we present a protocol of the transaxillary resection of the first rib for treatment of thoracic outlet syndrome caused by compression of the brachial plexus, subclavian vein and artery.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

A Training and Testing System for Performing Vascular Reconstruction In Vitro

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has yet to be developed. In this study, we introduce an in vitro training and testing system using a magnetic anchoring technique with which a trainee can practice manual vascular reconstruction individually. Additionally, this system can also be used to test the quality of the reconstruction. The described system includes a vascular reconstruction training machine, magnetic tractors, and a magnetic suture puller. In this manuscript, we detail an end-to-end vein anastomosis using porcine right and left iliac veins. To identify the potential damage caused by a magnetic suture puller on the suture, we created three groups with six segments of 4-0 polypropylene sutures each: a control group with no intervention on the polypropylene suture, a group in which the polypropylene suture is manually pulled with sterile gloves 20x, and a magnetic puller group in which the magnetic puller pulled the polypropylene suture 20x. These groups were tested by light microscopy and breaking strength tests, and the effect of reconstruction was assessed. In the light microscopy test, the control group was less likely to be damaged (p &#60; 0.05) and the number of damaged points of the manual group and magnetic puller group were similar (p &#62; 0.05). The results of the breaking strength test were compared across groups and no significant difference was observed (p &#62; 0.05). The end-to-end anastomosis of the porcine iliac veins was successfully performed using this training system, and the reconstructed veins could undergo 2.0 kPa perfusion pressure. Using this training and testing system the trainee can practice manual vascular reconstruction in vitro individually with the aid of magnetic tractors and a magnetic suture puller, and the quality of the reconstruction can be tested.

Here we present a training and testing system where a trainee can complete manual vascular reconstruction in vitro individually using a magnetic anchoring technique. The system can also be used to test the quality of reconstruction.

Manual vascular reconstruction training is essential for a beginner surgeon. However, an optimal training system for vascular reconstruction in vitro has ...

A Computerized Functional Skills Assessment and Training Program Targeting Technology Based Everyday Functional Skills

Today, many functional skills are technology-based, so development of a technology-based training program has broad importance. Here we present a computerized functional skills training program that was paired in half of the participants with a commercially available cognitive training (CCT) program.
Non-impaired older individuals (NC) aged 60+ (n=45) and similarly aged individuals with mild cognitive impairment (MCI; n=50) were randomized to receive 12 weeks of twice-weekly computerized functional skills training (CFST) or 12 weeks of twice-weekly sessions split between CCT and CFST. Skills trained were use of an ATM; internet banking; ticket kiosk; telephone and internet prescription refill; medication management; and internet shopping. As with previous functional capacity assessments, we focus on completion time for each simulation.
51 participants completed the training program, either by mastering all 6 tasks (34) or completing 12 weeks of training. 44 more participants completed 4 or more training sessions so they were also analyzed for improvement up to their last training session. Completion time for all 6 tests significantly improved from the baseline assessment to the final training session in both groups of participants (all p&#60;0.001 with an average improvement in task completion time of 45%). Further, there was no differential improvement in MCI and NC in the 6 tests from baseline to end of training (all t&#60;1.66, all p&#62;0.12). Finally, combined CCT plus CFST did not differ from CSFT alone on any of the percent-change score measures (all t&#60;1.64, all p&#62;0.11).
Both NC and MCI groups evidenced substantial improvements in performance. CCT supplementation led to similar functional gains with half as many training sessions. The NC participants proceeded through the training fairly rapidly even without CCT supplementation; MCI participants required more training but learned equivalently. These findings suggest that even in cases with memory impairments, functional skills can be efficiently learned with training.

This training protocol uses computerized training to teach technology-related everyday functional skills. These skills include financial skills, travel and transit, as well as medication management.