Skip to content
Licensed Unlicensed Requires Authentication Published by De Gruyter August 5, 2014

Combining virtual reality and a myoelectric limb orthosis to restore active movement after stroke: a pilot study

  • Sergi Bermúdez i Badia EMAIL logo , Ela Lewis and Scott Bleakley


We introduce a novel rehabilitation technology for upper limb rehabilitation after stroke that combines a virtual reality (VR) training paradigm with a myoelectric robotic limb orthosis. Our rehabilitation system is based on clinical guidelines and is designed to recruit specific motor networks to promote neuronal reorganization. The main hypothesis is that the restoration of active movement facilitates the full engagement of motor control networks during motor training. By using a robotic limb orthosis, we are able to restore active arm movement in severely affected stroke patients. In a pilot evaluation, we have successfully deployed and assessed our system with three chronic stroke patients by means of behavioral data and self-report questionnaires. The results show that our system is able to restore up to 60% of the active movement capability of patients. Further, we show that we can assess the specific contribution of the biceps/triceps movement of the paretic arm in a VR bilateral training task. Questionnaire data show enjoyment and acceptance of the developed rehabilitation system and its VR training task.

Corresponding author: Sergi Bermúdez i Badia, PhD, Universidade da Madeira, Campus Universitário da Penteada, 9020-105 Funchal, Portugal, E-mail:


The authors would like to thank Prof. Daniel P. Siewiorek (Carnegie Mellon University) and Steve Kelly (Myomo Inc.) for their support and contribution to this project. Support for this research was provided by the Fundação para a Ciência e Tecnologia (Portuguese Foundation for Science and Technology) through the Carnegie Mellon Portugal Program under grant CMU-Pt/0004/2007, and through the EC FP7 program under grant 303891 RehabNet FP7-PEOPLE-2011-CIG.


1. WHO. The global burden of disease: 2004 update. Geneva: World Health Organization, 2008.Search in Google Scholar

2. Esquenazi A. Falls and fractures in older post-stroke patients with spasticity: consequences and drug treatment considerations. Clin Geriatrics 2004;12:27–35.Search in Google Scholar

3. Lai SM, Studenski S, Duncan PW, Perera S. Persisting consequences of stroke measured by the Stroke Impact Scale. Stroke 2002;33:1840–4.10.1161/01.STR.0000019289.15440.F2Search in Google Scholar PubMed

4. Watkins CL, Leathley MJ, Gregson JM, Moore AP, Smith TL, Sharma AK. Prevalence of spasticity post stroke. Clin Rehabil 2002;16:515–22.10.1191/0269215502cr512oaSearch in Google Scholar PubMed

5. Sommerfeld DK, Eek EU, Svensson AK, Holmqvist LW, von Arbin MH. Spasticity after stroke: its occurrence and association with motor impairments and activity limitations. Stroke 2004;35:134–9.10.1161/01.STR.0000105386.05173.5ESearch in Google Scholar PubMed

6. Seitz RJ, Butefisch CM, Kleiser R, Homberg V. Reorganisation of cerebral circuits in human ischemic brain disease. Restor Neurol Neurosci 2004;22:207–29.Search in Google Scholar

7. Sabatini U, Toni D, Pantano P, Brughitta G, Padovani A, Bozzao L, et al. Motor recovery after early brain damage. A case of brain plasticity. Stroke 1994;25:514–7.10.1161/01.STR.25.2.514Search in Google Scholar PubMed

8. Dobkin BH. Training and exercise to drive poststroke recovery. Nat Clin Pract Neurol 2008;4:76–85.10.1038/ncpneuro0709Search in Google Scholar PubMed PubMed Central

9. Nudo RJ. Postinfarct cortical plasticity and behavioral recovery. Stroke 2007;38:840–5.10.1161/01.STR.0000247943.12887.d2Search in Google Scholar PubMed

10. Murphy TH, Corbett D. Plasticity during stroke recovery: from synapse to behaviour. Nat Rev Neurosci 2009;10:861–72.10.1038/nrn2735Search in Google Scholar PubMed

11. Hatsopoulos N. Rhythms in motor processing: functional implications for motor behavior. Short course organized by the Society for Neuroscience “Rhythms of the neocortex: Where do they come from and what are they good for. Washington, DC: Society for Neuroscience, 2009.Search in Google Scholar

12. Butefisch CM, Kleiser R, Seitz RJ. Post-lesional cerebral reorganisation: evidence from functional neuroimaging and transcranial magnetic stimulation. J Physiol Paris 2006;99:437–54.10.1016/j.jphysparis.2006.03.001Search in Google Scholar PubMed

13. Carel C, Loubinoux I, Boulanouar K, Manelfe C, Rascol O, Celsis P, et al. Neural substrate for the effects of passive training on sensorimotor cortical representation and colon; a study with functional magnetic resonance imaging in healthy subjects. J Cerebral Blood Flow Metabol 2000;20:478–84.10.1097/00004647-200003000-00006Search in Google Scholar PubMed

14. Szameitat AJ, Shen S, Conforto A, Sterr A. Cortical activation during executed, imagined, observed, and passive wrist movements in healthy volunteers and stroke patients. Neuroimage 2012;62:266–80.10.1016/j.neuroimage.2012.05.009Search in Google Scholar PubMed

15. Gallese V, Fadiga L, Fogassi L, Rizzolatti G. Action recognition in the premotor cortex. Brain 1996;119:593–609.10.1093/brain/119.2.593Search in Google Scholar

16. Keysers C, Kohler E, Umilta MA, Nanetti L, Fogassi L, Gallese V. Audiovisual mirror neurons and action recognition. Exp Brain Res 2003;153:628–36.10.1007/s00221-003-1603-5Search in Google Scholar

17. Kohler E, Keysers C, Umilta MA, Fogassi L, Gallese V, Rizzolatti G. Hearing sounds, understanding actions: action representation in mirror neurons. Science 2002;297:846–8.10.1126/science.1070311Search in Google Scholar

18. Altschuler EL, Wisdom SB, Stone L, Foster C, Galasko D, Llewellyn DM, et al. Rehabilitation of hemiparesis after stroke with a mirror. Lancet 1999;353:2035–6.10.1016/S0140-6736(99)00920-4Search in Google Scholar

19. Ertelt D, Small S, Solodkin A, Dettmers C, McNamara A, Binkofski F, et al. Action observation has a positive impact on rehabilitation of motor deficits after stroke. Neuroimage 2007;36:T164–73.10.1016/j.neuroimage.2007.03.043Search in Google Scholar PubMed

20. Merians AS, Tunik E, Fluet GG, Qiu Q, Adamovich SV. Innovative approaches to the rehabilitation of upper extremity hemiparesis using virtual environments. Eur J Phys Rehabil Med 2009;45:123–33.Search in Google Scholar

21. Michielsen ME, Selles RW, van der Geest JN, Eckhardt M, Yavuzer G, Stam HJ, et al. Motor recovery and cortical reorganization after mirror therapy in chronic stroke patients: a phase II randomized controlled trial. Neurorehabil Neural Repair 2011;25:223–33.10.1177/1545968310385127Search in Google Scholar PubMed

22. Rizzolatti G, Fabbri-Destro M, Cattaneo L. Mirror neurons and their clinical relevance. Nat Clin Pract Neurol 2009;5:24–34.10.1038/ncpneuro0990Search in Google Scholar PubMed

23. Hu XL, Tong K, Song R, Zheng XJ, Leung WW. A comparison between electromyography-driven robot and passive motion device on wrist rehabilitation for chronic stroke. Neurorehabil Neural Repair 2009;23:837.10.1177/1545968309338191Search in Google Scholar PubMed

24. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med 1975;7:13–31.Search in Google Scholar

25. Bohannon RW, Smith MB. Interrater reliability of a modified Ashworth scale of muscle spasticity. Phys Ther 1987;67:206–7.10.1093/ptj/67.2.206Search in Google Scholar PubMed

26. Kiguchi K, Tanaka T, Fukuda T. Neuro-fuzzy control of a robotic exoskeleton with EMG signals. Fuzzy Syst, IEEE Trans on 2004;12:481–90.10.1109/TFUZZ.2004.832525Search in Google Scholar

27. Tsagarakis NG, Caldwell DG. Development and control of a ‘soft-actuated’ exoskeleton for use in physiotherapy and training. Autonomous Robots 2003;15:21–33.10.1023/A:1024484615192Search in Google Scholar

28. Andreasen DS, Alien SK, Backus DA. Exoskeleton with EMG based active assistance for rehabilitation. 9th International Conference on Rehabilitation Robotics, ICORR, IEEE, 2005.Search in Google Scholar

29. Lucca LF. Virtual reality and motor rehabilitation of the upper limb after stroke: a generation of progress? J Rehabil Med 2009;41:1003–100.10.2340/16501977-0405Search in Google Scholar PubMed

30. Bermúdez i Badia S, Cameirão MS. The Neurorehabilitation Training Toolkit (NTT): a novel worldwide accessible motor training approach for at-home rehabilitation after stroke. Stroke Res Treat 2012;2012:802157.10.1155/2012/802157Search in Google Scholar PubMed PubMed Central

31. Cameirão MS, Bermúdez i Badia S, Duarte E, Verschure P. Neurorehabilitation using the virtual reality based rehabilitation gaming system: methodology, design, psychometrics, usability and validation. J Neuroeng Rehabil 2010;7:48.10.1186/1743-0003-7-48Search in Google Scholar PubMed PubMed Central

32. Cameirão MS, Bermúdez i Badia S, Duarte E, Frisoli A, Verschure PF. The combined impact of virtual reality neurorehabilitation and its interfaces on upper extremity functional recovery in patients with chronic stroke. Stroke 2012;43:2720–8.10.1161/STROKEAHA.112.653196Search in Google Scholar PubMed

33. Cameirão MS, Bermúdez i Badia S, Duarte E, Verschure P. Virtual reality based rehabilitation speeds up functional recovery of the upper extremities after stroke: a randomized controlled pilot study in the acute phase of stroke using the Rehabilitation Gaming System. Restor Neurol Neurosci 2011;29:287–98.Search in Google Scholar

34. Maclean N, Pound P, Wolfe C, Rudd A. Qualitative analysis of stroke patients’ motivation for rehabilitation. Br Med J 2000;321:1051–4.10.1136/bmj.321.7268.1051Search in Google Scholar PubMed PubMed Central

35. Stoykov ME, Stinear JW. Active-passive bilateral therapy as a priming mechanism for individuals in the subacute phase of post-stroke recovery: a feasibility study. Am J Phys Med Rehabil 2010;89:873.10.1097/PHM.0b013e3181f1c31cSearch in Google Scholar PubMed PubMed Central

36. Byblow WD, Stinear CM, Smith M-C, Bjerre L, Flaskager BK, McCambridge AB. Mirror symmetric bimanual movement priming can increase corticomotor excitability and enhance motor learning. PLoS One 2012;7:e33882.10.1371/journal.pone.0033882Search in Google Scholar PubMed PubMed Central

Received: 2013-4-8
Accepted: 2013-5-23
Published Online: 2014-8-5
Published in Print: 2014-9-1

©2014 by De Gruyter

Downloaded on 10.12.2023 from
Scroll to top button