Gamification in Musculoskeletal Rehabilitation

Perception and control of a virtual body in immersive virtual reality for rehabilitation

PURPOSE OF REVIEW

This review explores recent advances in using immersive virtual reality to improve bodily perception and motor control in rehabilitation across musculoskeletal and neurological conditions, examining how virtual reality's unique capabilities can address the challenges of traditional approaches. The potential in this area of the emerging metaverse and the integration of artificial intelligence in virtual reality are discussed.

RECENT FINDINGS

In musculoskeletal rehabilitation, virtual reality shows promise in enhancing motivation, adherence, improving range of motion, and reducing kinesiophobia, particularly postsurgery. For neurological conditions like stroke and spinal cord injury, virtual reality's ability to manipulate bodily perceptions offers significant therapeutic potential, with reported improvements in upper limb function and gait performance. Balance and gait rehabilitation, especially in older adults, have also seen positive outcomes. The integration of virtual reality with brain-computer interfaces presents exciting possibilities for severe speech and motor impairments.

SUMMARY

Current research is limited by small sample sizes, short intervention durations, and variability in virtual reality systems. Future studies should focus on larger, long-term trials to confirm findings and explore underlying mechanisms. As virtual reality technology advances, its integration into rehabilitation programs could revolutionize treatment approaches, personalizing treatments, facilitating home training, and potentially improving patient outcomes across a wide variety of conditions.

A robot-based hybrid lower limb system for Assist-As-Needed rehabilitation of stroke patients: Technical evaluation and clinical feasibility

BACKGROUND

Although early rehabilitation is important following a stroke, severely affected patients have limited options for intensive rehabilitation as they are often bedridden. To create a system for early rehabilitation of lower extremities in these patients, we combined the robotic manipulator ROBERT® with electromyography (EMG)-triggered functional electrical stimulation (FES) and developed a novel user-driven Assist-As-Needed (AAN) control. The method is based on a state machine able to detect user movement capability, assessed by the presence of an EMG-trigger and the movement velocity, and provide different levels of assistance as required by the patient (no support, FES only, and simultaneous FES and mechanical assistance).

METHODS

To technically validate the system, we tested 10 able-bodied participants who were instructed to perform specific behaviors to test the system states while conducting knee extension and ankle dorsal flexion exercises. The system was also tested on two stroke patients to establish its clinical feasibility.

RESULTS

The technical validation showed that the state machine correctly detected the participants' behavior and activated the target AAN state in more than 96% of the exercise repetitions. The clinical feasibility test showed that the system successfully recognized the patients' movement capacity and activated assistive states according to their needs providing the minimal level of support required to exercise successfully.

CONCLUSIONS

The system was technically validated and preliminarily proved clinically feasible. The present study shows that the novel system can be used to deliver exercises with a high number of repetitions while engaging the participants' residual capabilities through the AAN strategy.

Efficacy of virtual reality exercise in knee osteoarthritis rehabilitation: a systematic review and meta-analysis

Background

This systematic review and meta-analysis aims to investigate the effects of virtual reality (VR) exercise compared to traditional rehabilitation on pain, function, and muscle strength in patients with knee osteoarthritis (KOA). Additionally, the study explores the mechanisms by which VR exercise contributes to the rehabilitation of KOA patients.

Methods

We systematically searched PubMed, the Cochrane Library, Embase, Web of Science, Scopus, and PEDro according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Our search spanned from the library construction to 24 May 2024, focusing on randomized controlled trials Primary outcomes included pain, Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and muscle strength. Meta-analysis was conducted using RevMan (version 5.4) and Stata (version 14.0). The bias risk of included studies was assessed using the Cochrane RoB 2.0 tool, while the quality of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach.

Results

This meta-analysis and systematic review included nine studies involving 456 KOA patients. The results indicated that VR exercise significantly improved pain scores (SMD, -1.53; 95% CI: -2.50 to -0.55; p = 0.002), WOMAC total score (MD, -14.79; 95% CI: -28.26 to -1.33; p = 0.03), WOMAC pain score (MD, -0.93; 95% CI: -1.52 to -0.34; p = 0.002), knee extensor strength (SMD, 0.51; 95% CI: 0.14 to 0.87; p = 0.006), and knee flexor strength (SMD, 0.65; 95% CI: 0.28 to 1.01; p = 0.0005), but not significantly for WOMAC stiffness (MD, -0.01; 95% CI: -1.21 to 1.19; p = 0.99) and physical function (MD, -0.35; 95% CI: -0.79 to -0.09; p = 0.12).

Conclusion

VR exercise significantly alleviates pain, enhances muscle strength and WOMAC total score in KOA patients, but improvements in joint stiffness and physical function are not significant. However, the current number of studies is limited, necessitating further research to expand on the present findings.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42024540061, identifier CRD42024540061.

Integration of music-based game approaches with wearable devices for hand neurorehabilitation: a narrative review

BACKGROUND

Restoring hand functionality is critical for fostering independence in individuals with neurological disorders. Various therapeutic approaches have emerged to address motor function restoration, with music-based therapies demonstrating notable advantages in enhancing neuroplasticity, an integral component of neurorehabilitation. Despite the positive effects observed, there remains a gap in the literature regarding implementing music treatments in neurorehabilitation, such as Neurologic Music Therapy (NMT), especially in conjunction with emerging fields like wearable devices and game-based therapies.

METHODS

A literature search was conducted in various databases, including PubMed, Scopus, IEEE Xplore, and ACM Digital Library. The search was performed using a literature search methodology based on keywords. Information collected from the studies pertained to the approach used in music therapy, the design of the video games, and the types of wearable devices utilized.

RESULTS

A total of 158 articles were found, including 39 from PubMed, 34 from IEEE Xplore, 48 from Scopus, 37 from ACM Digital Library, and 35 from other sources. Duplicate entries, of which there were 41, were eliminated. In the first screening phase, 152 papers were screened for title and abstract. Subsequently, 89 articles were removed if they contained at least one exclusion criterion. Sixteen studies were considered after 63 papers had their full texts verified.

CONCLUSIONS

The convergence of NMT with emerging fields, such as gamification and wearable devices designed for hand functionality, not only expands therapeutic horizons but also lays the groundwork for innovative, personalized approaches to neurorehabilitation. However, challenges persist in effectively incorporating NMT into rehabilitation programs, potentially hindering its effectiveness.

Efficacy of interventions and techniques on adherence to physiotherapy in adults: an overview of systematic reviews and panoramic meta-analysis

BACKGROUND

Adherence to physiotherapeutic treatment and recommendations is crucial to achieving planned goals and desired health outcomes. This overview of systematic reviews synthesises the wide range of additional interventions and behaviour change techniques used in physiotherapy, exercise therapy and physical therapy to promote adherence and summarises the evidence of their efficacy.

METHODS

Seven databases (PEDro, PubMed, Cochrane Library, Web of Science, Scopus, PsycINFO and CINAHL) were systematically searched with terms related to physiotherapy, motivation, behaviour change, adherence and efficacy (last searched on January 31, 2023). Only systematic reviews of randomised control trials with adults were included. The screening process and quality assessment with AMSTAR-2 were conducted independently by the two authors. The extracted data was synthesised narratively. In addition, four meta-analyses were pooled in a panoramic meta-analysis.

RESULTS

Of 187 reviews identified in the search, 19 were included, comprising 205 unique trials. Four meta-analyses on the effects of booster sessions, behaviour change techniques, goal setting and motivational interventions showed a significantly small overall effect (SMD 0.24, 95% CI 0.13, 0.34) and no statistical heterogeneity (I2 = 0%) in the panoramic meta-analysis. Narrative synthesis revealed substantial clinical and methodological diversity. In total, the certainty of evidence is low regarding the efficacy of the investigated interventions and techniques on adherence, due to various methodological flaws. Most of the RCTs that were included in the reviews analysed cognitive and behavioural interventions in patients with musculoskeletal diseases, indicating moderate evidence for the efficacy of some techniques, particularly, booster sessions, supervision and graded exercise. The reviews provided less evidence for the efficacy of educational and psychosocial interventions and partly inconsistent findings. Most of the available evidence refers to short to medium-term efficacy. The combination of a higher number of behaviour change techniques was more efficacious.

CONCLUSIONS

The overview of reviews synthesised various potentially efficacious techniques that may be combined for a holistic and patient-centred approach and may support tailoring complex interventions to the patient's needs and dispositions. It also identifies various research gaps and calls for a more holistic approach to define and measure adherence in physiotherapy.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021267355.

Rehabilitation experiences following major lower limb amputation due to complications of vascular disease: a UK qualitative study

PURPOSE

Rehabilitation experiences of lower limb amputees with poorer physical health have not been fully explored. This study aimed to qualitatively explore experiences of rehabilitation amongst patients who had recently undergone amputation due to complications of vascular disease.

METHODS

Semi-structured, face-to-face interviews were conducted with 14 patients participating in the PLACEMENT randomised controlled feasibility trial (ISRCTN: 85710690; EudraCT: 2016-003544-37), which investigated the effectiveness of using a perineural catheter for postoperative pain relief following major lower limb amputation. Framework analysis was used to identify key themes and compare participant data.

FINDINGS

Three main themes and corresponding sub-themes were identified: (i) other patients as inspiration; (ii) other patients as competition; and (iii) imagined futures. Perceptions relating to other patients played a key role in rehabilitation, providing a source of motivation, support, and competition. Participants' imagined futures were uncertain, and this was compounded by a lack of information and delays in equipment and/or adaptations.

CONCLUSIONS

Findings highlight the importance of fellow patients in supporting rehabilitation following lower limb amputation. Enabling contact with other patients should thus be a key consideration when planning rehabilitation. There is a clear unmet need for realistic information relating to post-amputation recovery, tailored to the needs of individual patients.

Dropout From Exercise Interventions in Adults With Knee or Hip Osteoarthritis: A Systematic Review and Meta-analysis

OBJECTIVE

To investigate the prevalence and moderators of dropout rates among adults with knee or hip osteoarthritis participating in exercise randomized controlled trials (RCTs).

DATA SOURCES

Two authors searched Embase, CINAHL, PsycARTICLES, and PubMed up to 01/09/2023.

STUDY SELECTION

We included RCTs of exercise interventions in people with knee or hip osteoarthritis that reported dropout rates.

DATA EXTRACTION

Dropout rates from exercise and control conditions and exerciser/participant, provider, and design/implementation related moderators.

DATA SYNTHESIS

In total, 209 RCTs involving 277 exercise arms in 13,102 participants were included (mean age at study level=64 years; median prevalence of men participants=26.8%). The trim-and-fill-adjusted prevalence of dropout across all RCTs was 17.5% (95% CI=16.7%-18.2%), which is comparable with dropout observed in control conditions (trim-and-fill-adjusted odds ratio=0.89; 95% CI=0.71-1.12, P=.37). Higher prevalence of antidepressant use at study-level predicted higher dropout (R2=0.75, P=.002, N RCTs=6, n exercisers=412). Supervision by an exercise professional was associated with lower dropout rates, with a trim-and-fill-adjusted rate of 13.2% (95% CI=11.7%-14.9%) compared with 20.8% without supervision (95% CI=18.3%-23.5%) (P<.001).

CONCLUSIONS

Dropout rates for exercise in RCTs are comparable with control conditions, suggesting that exercise is a generally well-accepted intervention. However, interventions should be supervised by an exercise professional, such as a physiotherapist or exercise physiologist, to further minimize the risk of dropout. Health professionals should consider participants' use of antidepressants as a risk factor for dropout from exercise.

Improving adherence to rehabilitation for heart failure patients through immersive virtual reality (VIRTUAL-HF): A protocol for a randomized controlled trial

BACKGROUND

To improve symptoms and reduce poor outcomes related to heart failure (HF), international guidelines recommend cardiac rehabilitation (CR), particularly for those with a reduced ejection fraction. Unfortunately, patient adherence to rehabilitation programs remains suboptimal, with dropouts ranging from 15.4 to 63.3%. An innovative and promising intervention that could improve adherence to rehabilitation is virtual reality (VR). This study aims to evaluate the effects of VR in patients with HF who undergo CR using this technology in terms of adherence (primary outcome), functional capacity, perceived exertion, angina, quality of life, heart rate, oxygen saturation, blood pressure, maximum oxygen uptake, minute ventilation/carbon dioxide production slope, oxygen pulse, blood values of NT-proBNP and HF related rehospitalization rates (secondary outcomes).

METHODS

A randomized controlled trial will be conducted in a sample of 80 patients referred to CR. Participants will be enrolled in a cardiological rehabilitation unit of a large university hospital in Italy and randomized (1:1) to the experimental intervention consisting of CR performed with high-quality immersive VR with PICO 4® Head Mounted Display headset and TREADMILL XR® software (Arm 1) or standard CR (Arm 2). Patients, according to guidelines, will perform 30-min of CR sessions with moderate intensity, twice a week for one month.

RESULTS

Significant improvements in primary and secondary outcomes are expected in patients in the intervention group.

CONCLUSIONS

If proven to be effective, VR could be an innovative, safe, and easy digital health intervention to improve adherence to CR in patients with HF, as well as important clinical outcomes.

Leveraging Emerging Technologies to Expand Accessibility and Improve Precision in Rehabilitation and Exercise for People with Disabilities

Physical rehabilitation and exercise training have emerged as promising solutions for improving health, restoring function, and preserving quality of life in populations that face disparate health challenges related to disability. Despite the immense potential for rehabilitation and exercise to help people with disabilities live longer, healthier, and more independent lives, people with disabilities can experience physical, psychosocial, environmental, and economic barriers that limit their ability to participate in rehabilitation, exercise, and other physical activities. Together, these barriers contribute to health inequities in people with disabilities, by disproportionately limiting their ability to participate in health-promoting physical activities, relative to people without disabilities. Therefore, there is great need for research and innovation focusing on the development of strategies to expand accessibility and promote participation in rehabilitation and exercise programs for people with disabilities. Here, we discuss how cutting-edge technologies related to telecommunications, wearables, virtual and augmented reality, artificial intelligence, and cloud computing are providing new opportunities to improve accessibility in rehabilitation and exercise for people with disabilities. In addition, we highlight new frontiers in digital health technology and emerging lines of scientific research that will shape the future of precision care strategies for people with disabilities.

STASISM: A Versatile Serious Gaming Multi-Sensor Platform for Personalized Telerehabilitation and Telemonitoring

Telemonitoring and telerehabilitation have shown promise in delivering individualized healthcare remotely. We introduce STASISM, a sensor-based telerehabilitation and telemonitoring system, in this work. This platform has been created to facilitate individualized telerehabilitation and telemonitoring for those who need rehabilitation or ongoing monitoring. To gather and analyze pertinent and validated physiological, kinematic, and environmental data, the system combines a variety of sensors and data analytic methodologies. The platform facilitates customized rehabilitation activities based on individual needs, allows for the remote monitoring of a patient's progress, and offers real-time feedback. To protect the security of patient data and to safeguard patient privacy, STASISM also provides secure data transmission and storage. The platform has the potential to significantly improve the accessibility and efficacy of telerehabilitation and telemonitoring programs, enhancing patients' quality of life and allowing healthcare professionals to provide individualized care outside of traditional clinical settings.

Immersive virtual reality in orthopaedics-a narrative review

PURPOSE

This narrative review explores the applications and benefits of immersive virtual reality (VR) in orthopaedics, with a focus on surgical training, patient functional recovery, and pain management.

METHODS

The review examines existing literature and research studies on immersive VR in orthopaedics, analyzing both experimental and clinical studies.

RESULTS

Immersive VR provides a realistic simulation environment for orthopaedic surgery training, enhancing surgical skills, reducing errors, and improving overall performance. In post-surgical recovery and rehabilitation, immersive VR environments can facilitate motor learning and functional recovery through virtual embodiment, motor imagery during action observation, and virtual training. Additionally VR-based functional recovery programs can improve patient adherence and outcomes. Moreover, VR has the potential to revolutionize pain management, offering a non-invasive, drug-free alternative. Virtual reality analgesia acts by a variety of means including engagement and diverting patients' attention, anxiety reduction, and specific virtual-body transformations.

CONCLUSION

Immersive virtual reality holds significant promise in orthopaedics, demonstrating potential for improved surgical training, patient functional recovery, and pain management but further research is needed to fully exploit the benefits of VR technology in these areas.

Efficacy of rehabilitation treatments in improving functioning in patients with fibromyalgia: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Fibromyalgia is a debilitating condition marked by persistent pain and reduced functionality. Various therapeutic methods have been suggested to alleviate symptoms in individuals with fibromyalgia, yet the impact of diverse rehabilitation strategies remains unclear.

OBJECTIVE

This systematic review and meta-analysis aimed at assessing the efficacy of rehabilitation interventions in improving functioning in fibromyalgia patients.

METHODS

We conducted a comprehensive literature search of multiple international databases (PubMed, Scopus, and Web of Science) from their inception until November 22nd, 2023. We identified 23 randomized controlled trials (RCTs) assessing multiple rehabilitation strategies. The primary outcome was the Fibromyalgia Impact Questionnaire (FIQ). Study quality was assessed using the Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2). The study protocol was registered in PROSPERO (CRD42020197666).

RESULTS

Our meta-analysis rehabilitation interventions significantly reduce FIQ scores (MD =-11.74, 95% CI: -16.88 to -6.59, p< 0.0001). Notably, the subgroup analysis showed that different rehabilitation modalities seem to induce different therapeutic responses.

CONCLUSIONS

Rehabilitation strategies hold promise in addressing the functional impairments and improving the overall well-being of individuals with fibromyalgia. The study underscores the need for further research to determine the optimal rehabilitation approach and its potential impact on the multilevel disability characterizing patients with fibromyalgia.

Exergaming (physically active video gaming) for mental health service users in a community mental health care setting: an ethnographic observational feasibility study

BACKGROUND

People with severe and enduring mental illness experience health inequalities with premature mortality; lifestyle behaviours are known to be contributing factors with low levels of physical activity reported. Facilitating physical activity to help maintain or improve health for those who are disadvantaged is essential. Exergaming (gaming involving physical movement) is increasingly used to improve physical activity across the lifespan and for those with a range clinical conditions; this might offer a way to increase physical activity for those with severe mental illness. The aim of this study was to explore engagement of mental health service users with exergaming to increase physical activity in a community mental health care setting.

METHODS

An ethnographic observational feasibility study was undertaken through participant observation and semi-structured interviews. A gaming console was made available for 2 days per week for 12 months in a community mental health setting. A reflexive thematic analysis was performed on the data.

RESULTS

Twenty one mental health service users engaged with the intervention, with two thirds exergaming more than once. One participant completed the semi-structured interview. Key themes identified from the observational field notes were: support (peer and staff support); opportunity and accessibility; self-monitoring; and perceived benefits. Related themes that emerged from interview data were: benefits; motivators; barriers; and delivery of the intervention. Integrating these findings, we highlight social support; fun, enjoyment and confidence building; motivation and self-monitoring; and, accessibility and delivery in community mental health care context are key domains of interest for mental health care providers.

CONCLUSIONS

We provide evidence that exergaming engages people with SMI with physical activity. The value, acceptability and feasibility of open access exergaming in a community mental health service context is supported. Facilitating exergaming has the potential to increase physical activity for mental health service users leading to possible additional health benefits.

The Association of Technology-Based Ageism with Using Digital Technology in Physical Therapy for Older Persons

Integrating digital technologies in healthcare for older adults can enhance their independence and quality of life. Nevertheless, ageism among healthcare professionals impacts treatment decisions and may deprive older patients of technology-based treatment. This study explores whether technology-specific ageism influenced physiotherapists' use of technology-based healthcare with older patients. Seventy-eight physiotherapists in Luxembourg filled out an online survey. Participants filled out the Attitudes Towards Older Adults Using Technology (ATOAUT-11) scale, Expectations Regarding Aging, attitudes towards technology use in the work environment, and whether they had not offered technology-based treatment in the past because of a patient's age. Using logistic regression, negative ATOAUT was found to predict not offering technology-based treatment, such that participants with more negative attitudes (1 standard deviation) were two times more likely not to offer treatment. Positive attitudes towards using technology in the work environment were also found to be a significant predictor. All other characteristics (gender, age, experience and percentage of patients over 50) were not predictive of not offering treatment. This study demonstrates that technology-specific ageism may lead to discrimination and deprive older persons of optimal treatment. More research is needed to identify the magnitude of ageism in using technology-based treatment and develop interventions to overcome it.

Rehabilitation for Musculoskeletal Disorders: The Emergence of Serious Games and the Promise of Personalized Versions Using Artificial Intelligence

According to the World Health Organization (WHO), musculoskeletal conditions are among the most common health problems, affecting approximately 1 [...].

Positive and Negative Impacts of Gamification on the Fitness Industry

Gamification features to motivate individuals to exercise have become a trend in the fitness sector that is gaining popularity. It is based on the idea that adding fun and competitive components to workout routines will inspire people to achieve their fitness objectives and maintain a healthy lifestyle. This research study attempts to analyze the literature that explores this concept of gamification in detail, and create a picture of how its implementation has changed fitness and healthy habits. This research incorporated the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) approach as its research methodology. Search strategy used a set of inclusion-exclusion criteria that helped us examine through hundreds of articles identified in the Web of Science and SCOPUS databases. After exclusive and inclusion criteria, 48 articles were selected to be reviewed in detail. Results have indicated that gamification strategy is a supporting factor to overcome the difficulties of executing exercises. Also, to improve the willingness towards fitness regimens.

Home-Based Exergame Program to Improve Physical Function, Fall Efficacy, Depression and Quality of Life in Community-Dwelling Older Adults: A Randomized Controlled Trial

This study aimed to investigate the effects of home-based exergame programs on physical function, fall efficacy, depression, and health-related quality of life in community-dwelling older adults. Fifty-seven participants aged 75 years or older were divided into control and experimental groups. The experimental group received a home-based exergame program that included balance and lower-extremity muscle strength for 8 weeks. The participants exercised at home for 50 min three times a week and were monitored through a video-conference application. Both groups received online education on musculoskeletal health once a week, whereas the control group did not exercise. Physical function was assessed using the one-leg standing test (OLST), Berg balance scale (BBS), functional reaching test (FRT), timed up-and-go test (TUGT), and five-times sit-to-stand (FTSTS). Fall efficacy was assessed using the modified falls efficacy scale (MFES). Depression was assessed using the geriatric depression scale (GDS). Health-related quality of life was assessed using a 36-item short-form health survey (SF-36). The experimental group showed an overall improvement in OLST, BBS, FRT, TUGT, and FTSTS (p < 0.05). MFES was significantly increased in the experimental group after the intervention (p < 0.05). The GDS significantly decreased in the experimental group after the intervention (p < 0.05). In SF-36, role limitations due to physical health, general health, and fatigue (energy and fatigue) items improved in the experimental group after intervention (p < 0.05). An 8-week home-based exergame program improved physical function, fall efficacy, depression, and health-related quality of life in older adults. The study was registered on ClinicalTrials.gov (NCT05802537).

Integrating Rehabilomics into the Multi-Omics Approach in the Management of Multiple Sclerosis: The Way for Precision Medicine?

Over recent years, significant improvements have been made in the understanding of (epi)genetics and neuropathophysiological mechanisms driving the different forms of multiple sclerosis (MS). For example, the role and importance of the bidirectional communications between the brain and the gut-also referred to as the gut-brain axis-in the pathogenesis of MS is receiving increasing interest in recent years and is probably one of the most promising areas of research for the management of people with MS. However, despite these important advances, it must be noted that these data are not-yet-used in rehabilitation. Neurorehabilitation is a cornerstone of MS patient management, and there are many techniques available to clinicians and patients, including technology-supported rehabilitation. In this paper, we will discuss how new findings on the gut microbiome could help us to better understand how rehabilitation can improve motor and cognitive functions. We will also see how the data gathered during the rehabilitation can help to get a better diagnosis of the patients. Finally, we will discuss how these new techniques can better guide rehabilitation to lead to precision rehabilitation and ultimately increase the quality of patient care.