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Latimer N, Reelfs A, Halbert J, Hansen J, Miller A, Barton C, Stuhr J, Zaman A, Stegemöller EL. The effects of auditory cues and weighted pens on handwriting in individuals with Parkinson's disease. J Hand Ther 2024; 37:144-152. [PMID: 37778882 DOI: 10.1016/j.jht.2023.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 07/26/2023] [Accepted: 08/08/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Micrographia, or small handwriting, is a common symptom of Parkinson's disease (PD). Weighted pens have previously been recommended to improve handwriting, but there is limited research supporting their effectiveness. Additionally, previous research has demonstrated that music as an auditory cue can reduce variability in fine motor movements, but its effect on handwriting in people with PD remains unknown. PURPOSE This study explored potential handwriting interventions for people with PD by evaluating the effectiveness of weighted pens and auditory cues on handwriting. STUDY DESIGN This was a pilot cohort study. METHODS Eight older adults with PD used a standard pen and a weighted pen to write continuous cursive "l"s on 1.5-cm-lined paper for a total of 10 seconds while listening to auditory cues in 4 conditions: control (silence), metronome, activating music, and relaxing music. Kinematic data were measured with sensors attached to the tip of each pen, and muscle activity was measured with electromyography sensors adhered to the extensor digitorum communis and first dorsal interosseous. RESULTS When writing with the standard pen, peak-to-peak time was reduced in the metronome (control = 0.807 ± 0.121 seconds, metronome = 0.701 ± 0.100 seconds, p = 0.024) and activating (control = 0.807 ± 0.121 seconds, activating = 0.691 ± 0.113 seconds, p = 0.009) conditions compared to the control condition. Furthermore, the weighted pen increased the variability of distance between letter peaks (standard = 0.187 ± 0.010, weighted = 0.482 ± 0.065, p = 0.033) and the variability of time needed to complete each letter (standard = 0.176 ± 0.010, weighted = 0.187 ± 0.016, p = 0.042) compared to the standard pen. Finally, area under the curve of the extensor digitorum communis was reduced in the metronome (metronome = 66.03 ± 25.74 mV, control = 88.98 ± 30.40 mV, p = 0.034) and activating music (activating = 66.49 ± 26.02 mV, control = 88.98 ± 30.40 mV, p = 0.012) conditions compared to control when writing with the standard pen. CONCLUSIONS These results suggest that weighted pens may not improve handwriting in novice users, but auditory cues appear beneficial. This can inform future directions in the research and clinical application of handwriting interventions for persons with PD.
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Affiliation(s)
- Nicole Latimer
- Department of Kinesiology, Iowa State University, Ames, IA, USA
| | - Anna Reelfs
- Department of Kinesiology, Iowa State University, Ames, IA, USA
| | - Jamie Halbert
- Department of Kinesiology, Iowa State University, Ames, IA, USA
| | - Julia Hansen
- Department of Kinesiology, Iowa State University, Ames, IA, USA
| | - Ashley Miller
- Department of Kinesiology, Iowa State University, Ames, IA, USA
| | - Chloe Barton
- Department of Kinesiology, Iowa State University, Ames, IA, USA
| | - Jamie Stuhr
- Department of Kinesiology, Iowa State University, Ames, IA, USA
| | - Andrew Zaman
- Department of Kinesiology, Iowa State University, Ames, IA, USA
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Gardoni A, Sarasso E, Agosta F, Filippi M, Corbetta D. Rehabilitative interventions for impaired handwriting in people with Parkinson's disease: a scoping review. Neurol Sci 2023:10.1007/s10072-023-06752-6. [PMID: 36964814 DOI: 10.1007/s10072-023-06752-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 03/12/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND People with Parkinson's disease (PD) often complain about handwriting difficulties. Currently, there is no consensus on the rehabilitative treatment and outcome measures for handwriting rehabilitation in PD. OBJECTIVES This study aims to investigate evidence on handwriting rehabilitation in people with PD, examining characteristics of interventions and outcomes. METHODS A scoping review was conducted according to Arksey and O'Malley's framework and PRISMA-ScR List. We searched electronic databases of PubMed, Physiotherapy Evidence Database, Cochrane Central Register of Controlled Trials, and Embase since inception to January 2023. We included interventional studies assessing the effects of structured rehabilitation programs for impaired handwriting in people with PD. Two reviewers independently selected studies, extracted data, and assessed the risk of bias using the Cochrane Collaboration's tool for assessing Risk of Bias version 2 or the Risk Of Bias In Non-randomized Studies. We performed a narrative analysis on training characteristics and assessed outcomes. RESULTS We included eight studies. The risk of bias was generally high. Either handwriting-specific or handwriting-non-specific trainings were proposed, and most studies provided a home-based training. Handwriting-specific training improved writing amplitude while handwriting-non-specific trainings, such as resistance and stretching/relaxation programs, resulted in increased writing speed. CONCLUSIONS The current knowledge is based on few and heterogeneous studies with high risk of bias. Handwriting-specific training might show potential benefits on handwriting in people with PD. Further high-quality randomized controlled trials are needed to reveal the effect of handwriting training in people with PD on standardized outcome measures. Handwriting-specific training could be combined to resistance training and stretching, which seemed to influence writing performance.
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Affiliation(s)
- Andrea Gardoni
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Rehabilitation and Functional Recovery, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Elisabetta Sarasso
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Department of Rehabilitation and Functional Recovery, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal Child Health, University of Genoa, Genoa, Italy
| | - Federica Agosta
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Massimo Filippi
- Neuroimaging Research Unit, Division of Neuroscience, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Vita-Salute San Raffaele University, Milan, Italy
- Neurology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurorehabilitation Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Neurophysiology Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Davide Corbetta
- Department of Rehabilitation and Functional Recovery, IRCCS San Raffaele Scientific Institute, Milan, Italy.
- Vita-Salute San Raffaele University, Milan, Italy.
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Delier HB, Katirci Kirmaci ZI, Adiguzel H, Demirguc A. The relationship of tremor severity with proximal and distal muscle strength and upper extremity functional skills in older adults with essential tremor. Eur Geriatr Med 2023; 14:381-387. [PMID: 36932286 DOI: 10.1007/s41999-023-00766-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Accepted: 03/05/2023] [Indexed: 03/19/2023]
Abstract
BACKGROUND Although it is known that muscle strength training is effective in Essential Tremor (ET), it is not known which muscle groups are more affected. AIM The study was conducted to examine the relationship between tremor severity and proximal and distal muscle strength and upper extremity functional skills in older adults with ET. METHODS A total of 40 older adults who were diagnosed with ET (mean age of 74.07 ± 4.83 years) and 40 older adults without tremor (mean age of 70.10 ± 4.05 years) were included in the study. Tremor severity was evaluated with the Fahn-Tolosa-Marin Tremor Rating Scale (FTMTRS), the proximal muscular strength with digital muscle dynamometer, handgrip strength with hand dynamometer, and pinch grip strength with pinchmeter. The Arm and Shoulder Problems Questionnaire (DASH) was used to determine the functional status of the upper extremities. Fine Manual Dexterity was measured with the Nine-Hole Peg Test (NHPT). RESULTS All proximal and distal muscle strengths were significantly lower, DASH and NHPT were significantly higher in the group with ET (p < 0.05). A significant negative correlation was detected between tremor severity and all proximal and distal muscular strength and a significant positive correlation between tremor severity and DASH in group with ET (p < 0.05). However, no significant correlations were found between tremor severity and NHPT in the group with ET. CONCLUSIONS It was found that older adults who had tremors had low proximal and distal muscular strength, upper extremity functionality was affected and hand skills was impaired. Furthermore tremor severity is affected by both proximal and distal muscle strength.
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Affiliation(s)
- Hatice Busra Delier
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, SANKO University, Gaziantep, Turkey
| | - Zekiye Ipek Katirci Kirmaci
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Kahramanmaraş Sutcu Imam University, Ismetpasa Neighbourhood, Emniyet Street, No:2 D:C Block, Dulkadiroglu, 46050, Kahramanmaras, Turkey.
| | - Hatice Adiguzel
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, Kahramanmaraş Sutcu Imam University, Ismetpasa Neighbourhood, Emniyet Street, No:2 D:C Block, Dulkadiroglu, 46050, Kahramanmaras, Turkey
| | - Arzu Demirguc
- Faculty of Health Sciences, Department of Physiotherapy and Rehabilitation, SANKO University, Gaziantep, Turkey
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Park W, Kim B, Lee J, Hong G, Park J. Relationship between physiological tremor and cognitive function in physically active older women. Phys Act Nutr 2022; 26:14-19. [PMID: 35510441 PMCID: PMC9081354 DOI: 10.20463/pan.2022.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 03/30/2022] [Indexed: 11/24/2022] Open
Abstract
[Purpose] This study aimed to compare the physiological tremor, grip strength, and cognitive function of sedentary and physically active older adults. [Methods] Twenty-four older adults aged ≥65 years participated in this study and were divided into the sedentary (76.5±4.4 years, n=12) and physically active (73.5±3.3 years, n=12) groups. Each group completed the Mini-Mental State Examination (MMSE) for cognitive function assessment. Physiological tremor was measured using an accelerometer for both hands at rest and the left/right hand with a 1,000 g dumbbell on the palm in neutral positions and the elbow flexed at 90°. Physical fitness was measured by grip strength and completion of the Short Physical Performance Battery (SPPB) and the 6-min walk test. [Results] The physically active group showed a significantly lower level of physiological tremor in both hands at rest and the left/right hand with a 1,000 g dumbbell on the palm (P<0.05) than that in the sedentary group. For cognitive function, the physically active group showed significantly higher scores than those in the sedentary group (P<0.001). No significant correlation was found between cognitive function and left/right grip strength (left: r = 0.117, P = 0.585; right: r = 0.230, P = 0.279), physiological tremor in both hands at rest (left: r = -0.524, P < 0.001; right: r = -0.508, P < 0.05), and the left/right hand with a 1,000 g dumbbell on the palm (left: r = -0.505, P < 0.05; right: r = -0.458, P < 0.05). [Conclusion] Physiological tremor of the hands has the potential to be a useful predictor of cognitive function in older adults.
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Sahandi Far M, Eickhoff SB, Goni M, Dukart J. Exploring Test-Retest Reliability and Longitudinal Stability of Digital Biomarkers for Parkinson Disease in the m-Power Data Set: Cohort Study. J Med Internet Res 2021; 23:e26608. [PMID: 34515645 PMCID: PMC8477293 DOI: 10.2196/26608] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 06/21/2021] [Accepted: 07/05/2021] [Indexed: 02/05/2023] Open
Abstract
Background Digital biomarkers (DB), as captured using sensors embedded in modern smart devices, are a promising technology for home-based sign and symptom monitoring in Parkinson disease (PD). Objective Despite extensive application in recent studies, test-retest reliability and longitudinal stability of DB have not been well addressed in this context. We utilized the large-scale m-Power data set to establish the test-retest reliability and longitudinal stability of gait, balance, voice, and tapping tasks in an unsupervised and self-administered daily life setting in patients with PD and healthy controls (HC). Methods Intraclass correlation coefficients were computed to estimate the test-retest reliability of features that also differentiate between patients with PD and healthy volunteers. In addition, we tested for longitudinal stability of DB measures in PD and HC, as well as for their sensitivity to PD medication effects. Results Among the features differing between PD and HC, only a few tapping and voice features had good to excellent test-retest reliabilities and medium to large effect sizes. All other features performed poorly in this respect. Only a few features were sensitive to medication effects. The longitudinal analyses revealed significant alterations over time across a variety of features and in particular for the tapping task. Conclusions These results indicate the need for further development of more standardized, sensitive, and reliable DB for application in self-administered remote studies in patients with PD. Motivational, learning, and other confounders may cause variations in performance that need to be considered in DB longitudinal applications.
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Affiliation(s)
- Mehran Sahandi Far
- Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Jülich, Germany.,Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Simon B Eickhoff
- Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Jülich, Germany.,Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Maria Goni
- Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Jülich, Germany.,Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Juergen Dukart
- Institute of Neuroscience and Medicine, Brain & Behaviour (INM-7), Research Centre Jülich, Jülich, Germany.,Institute of Systems Neuroscience, Medical Faculty, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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Sharma N, Kaur M, Goyat A, Sharma P, Srivastav AK, Agrawal BK. Therapeutic Regime to Ameliorate Quality of Life in Patients with Parkinson’s Disease. PHYSICAL & OCCUPATIONAL THERAPY IN GERIATRICS 2021. [DOI: 10.1080/02703181.2021.1973172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Nidhi Sharma
- Department of Neurological Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India
| | - Manpreet Kaur
- Department of Neurological Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India
| | - Anju Goyat
- Department of Neurological Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India
| | - Priyanka Sharma
- Department of Neurological Physiotherapy, Maharishi Markandeshwar Institute of Physiotherapy and Rehabilitation, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India
| | - Adarsh Kumar Srivastav
- Department of Physiotherapy, Maharishi Markandeshwar Medical College and Hospital, Maharishi Markandeshwar University, Kumarahatti-Solan, Himachal Pradesh, India
| | - B. K. Agrawal
- Department of Medicine, Maharishi Markandeshwar Institute of Medical Science and Research, Maharishi Markandeshwar (Deemed to be University), Mullana, Haryana, India
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Cikajlo I, Pogačnik M. Movement analysis of pick-and-place virtual reality exergaming in patients with Parkinson's disease. Technol Health Care 2021; 28:391-402. [PMID: 32200361 DOI: 10.3233/thc-191700] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Reduced coordination of precise small movements of the hand, wrist and fingers in Parkinson's disease (PD) has been mostly solved by medications and deep brain stimulation. The effects have been evaluated by clinical tests only. OBJECTIVE Virtual reality-based exergaming may enhance fine movements, decrease the medications dosage and provide an additional non-subjective evaluation. METHODS 3D pick-and-place task (10Cubes) has been developed in a virtual world. The person placed the virtual cubes by the virtual hand, an avatar of the real hand tracked by a Leap Motion Controller (LMC). The system computed the time of manipulating the cube, the total time, the average time, the speed, and the distance. It counted and managed the number of cubes touched, and calculated the hand shake level, i.e. the average tremor index. A pilot test was carried out in a healthy neurologically intact person and a patient with PD using a 3D head-mounted device (HMD) or LCD screen. RESULTS The results indicate that substantial and also statistically significant (p< 0.05) differences exist between both participants in all objective parameters; the most noteworthy is the average tremor index. However, we found the parameters only marginally different with 2D equipment. CONCLUSIONS The evaluation system of 10Cubes has proved applicable at an unchanged medication plan, but its clinical effectiveness could be confirmed with a randomized study.
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Affiliation(s)
- Imre Cikajlo
- University Rehabilitation Institute, SI-1000 Ljubljana, Slovenia.,School of Engineering and Management, University of Nova Gorica, SI-5000 Nova Gorica, Slovenia
| | - Matevž Pogačnik
- Faculty of Electrical Engineering, University of Ljubljana, SI-1000 Ljubljana, Slovenia
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Kadkhodaie M, Sharifnezhad A, Ebadi S, Marzban S, Habibi SA, Ghaffari A, Forogh B. Effect of eccentric-based rehabilitation on hand tremor intensity in Parkinson disease. Neurol Sci 2019; 41:637-643. [PMID: 31735996 DOI: 10.1007/s10072-019-04106-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 10/11/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE Hand tremor is a disturbing yet sometimes resistant symptom in persons with Parkinson disease (PD). Although many exercise regimens for these people have gained attention in recent years, the effect of resistance training and especially eccentric training on parkinsonian tremor is still uncertain. This study was conducted to investigate the precise effect of upper limb eccentric training on hand tremor in PD. METHODS In this randomized controlled trial, a consecutive sample of 21 persons with PD recruited from general hospitals went through 6 weeks of upper limb pure eccentric training as the intervention group (n = 11) or no additional exercise during this period as the control group (n = 10). Resting and postural tremor amplitudes were measured with the cellphone-based accelerometer. RESULTS Comparing hand tremor amplitudes before and after the trial showed a significant reduction in resting tremor amplitude in the intervention group after exercise sessions (p < 0.05) while detecting no changes in the control group during 6 weeks of study. Meanwhile, postural tremor amplitude remained unchanged in both groups.
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Affiliation(s)
- Mona Kadkhodaie
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Firoozgar Hospital, Behafarin St., Karim Khan St., Tehran, Iran
| | - Ali Sharifnezhad
- Department of Sport Biomechanics and Technology, Sport Sciences Research Institute, No 3, Alley 5, Mir Emad St., Motahari St., Tehran, Iran.
| | - Safoora Ebadi
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Firoozgar Hospital, Behafarin St., Karim Khan St., Tehran, Iran
| | - Sadegh Marzban
- Department of Biomedical Engineering, Amirkabir University of Technology, Tehran, Iran
| | | | - Amin Ghaffari
- School of Rehabilitation Science, Iran University of Medical Sciences, Tehran, Iran
| | - Bijan Forogh
- Neuromusculoskeletal Research Center, Department of Physical Medicine and Rehabilitation, Iran University of Medical Sciences, Firoozgar Hospital, Behafarin St., Karim Khan St., Tehran, Iran.
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Cikajlo I, Peterlin Potisk K. Advantages of using 3D virtual reality based training in persons with Parkinson's disease: a parallel study. J Neuroeng Rehabil 2019; 16:119. [PMID: 31623622 PMCID: PMC6798369 DOI: 10.1186/s12984-019-0601-1] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 09/25/2019] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Parkinson's disease (PD) is a slowly progressive neurodegenerative disease. There are mixed reports on success of physiotherapy in patients with PD. Our objective was to investigate the functional improvements, motivation aspects and clinical effectiveness when using immersive 3D virtual reality versus non-immersive 2D exergaming. METHODS We designed a randomized parallel study with 97 patients, but only 20 eligible participants were randomized in 2 groups; the one using 3D Oculus Rift CV1 and the other using a laptop. Both groups participated in the 10-session 3 weeks training with a pick and place task in the virtual world requiring precise hand movement to manipulate the virtual cubes. The kinematics of the hand was traced with Leap motion controller, motivation effect was assessed with modified Intrinsic Motivation Inventory and clinical effectiveness was evaluated with Box & Blocks Test (BBT) and shortened Unified Parkinson's disease rating scale (UPDRS) before and after the training. Mack-Skilling non-parametrical statistical test was used to identify statistically significant differences (p < 0.05) and Cohen's U3 test to find the effect sizes. RESULTS Participants in the 3D group demonstrated statistically significant and substantially better performance in average time of manipulation (group x time, p = 0.009), number of successfully placed cubes (group x time, p = 0.028), average tremor (group x time, p = 0.002) and UPDRS for upper limb (U3 = 0.35). The LCD and 3D groups substantially improved their BBT score with training (U3 = 0.7, U3 = 0.6, respectively). However, there were no statistically significant differences in clinical tests between the groups (group x time, p = 0.2189, p = 0.2850, respectively). In addition the LCD group significantly decreased the pressure/tension (U3 = 0.3), the 3D did not show changes (U3 = 0.5) and the differences between the groups were statistically different (p = 0.037). The 3D group demonstrated important increase in effort (U3 = 0.75) and perceived competences (U3 = 0.9). CONCLUSIONS The outcomes of the study demonstrated that the immersive 3D technology may bring increased interests/enjoyment score resulting in faster and more efficient functional performance. But the 2D technology demonstrated lower pressure/tension score providing similar clinical progress. A study with much larger sample size may also confirm the clinical effectiveness of the approaches. TRIAL REGISTRATION The small scale randomized pilot study has been registered at ClinicalTrials.gov Identifier: NCT03515746 , 4 May 2018.
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Affiliation(s)
- Imre Cikajlo
- University Rehabilitation Institute, Republic of Slovenia, Linhartova 51, SI-1000 Ljubljana, Slovenia
- School of Engineering and Management, University of Nova Gorica, Vipavska 13, SI-5000 Nova Gorica, Slovenia
| | - Karmen Peterlin Potisk
- University Rehabilitation Institute, Republic of Slovenia, Linhartova 51, SI-1000 Ljubljana, Slovenia
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