Functional Viability Duck Duck Punch

Stroke is a problem nationally, but especially in the southeastern USA, a region known as the
"stroke belt" where stroke incidence is high and age of stroke onset is low. The vast
majority, >75%, of stroke survivors experience paresis of one arm/hand that does not resolve
acutely. Long-term arm movement impairment restricts independence with self-care and
vocational activities, increases caregiver burden and reduces quality of life. Although
rehabilitation improves outcomes, systematic financial pressures increasingly limit its
duration. Unfortunately, this is happening at a time when strong evidence is emerging that
traditional therapy programs do not provide adequate amounts of movement practice needed for
motor recovery. Thus, there is a need for innovative technology to augment traditional stroke
rehabilitation programs in a way that can provide the necessary movement practice within the
constraints of current rehabilitation practice.

To meet this need, the Principal Investigators developed a prototype Kinect-based post-stroke
rehabilitation game called Duck Duck Punch (DDP). While maintaining the appeal of a game, DDP
has a therapeutic focus because its unique design elicits an arm motor recovery process
consistent with evidence-based stroke rehabilitation principles. The player moves his/her
physical arm to control an avatar arm to reach and "punch" virtual ducks. Custom features
allow tailoring of game difficulty to match a player's impairment level so that the player
seeks to accomplish optimally challenging movement goals. By design, the avatar does not
respond to atypical arm motions, which encourages the player to trial and error a variety of
motions until implicitly learning the more normal strategy. Thus, unlike most commercially
available "off the shelf" games, success requires "therapist approved" healthy arm motions.
Success motivates continued game play for extended practice of healthy motions. Therapists
can integrate DDP into in-clinic or in-home therapies for additional quasi-supervised
movement practice and receive a performance report that quantifies and monitors progress
toward recovery goals. Further development of this report will enable its integration into a
billable rehabilitation program.

The Investigators licensed DDP and formed a company, Recovr, which has received investment
funding for initial start-up and market research. Of note, DDP has also received FDA 510(k)
Clearance to "support physical rehabilitation of adults in the clinic and at home via
performance of therapist-assigned reach exercises for the upper extremities." In a funded
NIH/NIGMS pilot project, the investigators established the technical merit and feasibility of
DDP as a tool to augment inpatient, outpatient and home-based stroke rehabilitation by
increasing therapist- and patient-directed movement practice opportunities. Very promising
results motivated the current project that seeks to test the functional viability of DDP and
determine its commercial potential.

Inclusion Criteria:

- experienced unilateral hemispheric ischemic or hemorrhagic stroke at least 3 months
but no more than 7 years prior

- exhibit voluntarily shoulder flexion of the affected arm ≥30° with simultaneous elbow
extension ≥20°. The investigators reason that persons at this motor ability level have
residual arm activation and enough ability to engage in treatment-related reaching
movements elicited by the computer games

- baseline FMA-UE score of at least 19 points but no more than 52 points (out of 60
points) based on previously published research by this study's investigators in which
categories were defined based on post-stroke UE motor impairment

- passive range of motion in affected shoulder, elbow and wrist within 20 degrees of
normal values

- 21-90 years of age

- a caregiver or friend who is willing to assist with the set up and operation of the
computer game throughout the 6 week intervention.

Exclusion Criteria:

- lesion in brainstem or cerebellum because lesions in these locations my interfere with
the visual-perceptual and cognitive skills needed for motor re-learning as is expected
to occur as a result of the intervention

- presence of other neurological disease that may impair motor skills (e.g., Parkinson's
Disease)

- pain in the affected arm that interferes with reaching movements

- significant cognitive impairment, defined as Montreal Cognitive Assessment score < 22

- orthopedic condition or impaired corrected vision that alters the kinematics of
reaching

- unable to travel to the UE Motor Function Laboratory in Charleston, South Carolina 4
times (pre-, mid- post- and retention testing).