Applying Game-Based Approaches for Physical Rehabilitation of Poststroke Patients: A Systematic Review

Design and evaluation of a serious video game to treat preschool children with speech sound disorders

Speech sound disorder (SSD) is one of the most common communication disorders in children, which must be diagnosed and treated in childhood to prevent its negative psychological, occupational, and social consequences in adulthood. The use of serious games is one technology that could help treat SSD. This study aims to design and evaluate the usability of a digital game for 3-6-year-old children. This developmental study was carried out in three main stages: determining information requirements, designing and developing a digital game, and evaluating the usability of the designed game. In the first stage, the consonants, syllables, words, and sentences that should be used in the game were determined through focus group sessions and a questionnaire completed by 30 speech-language pathologists (SLPs) in two Delphi rounds. In the designing and developing stage, the game design document was first written, and then sketches and wireframes were drawn based on this document. Then, the game was developed in the second phase using Java programming language. In the third stage, the usability of the designed game was evaluated by six experts and 22 SLPs using Nielsen's usability heuristics and the Post-Study System Usability Questionnaire (PSSUQ), respectively. Also, the usability of the game was evaluated by ten children. To determine the information requirements, SLPs confirmed 23 consonants, 138 syllables, 564 words, and 69 sentences to teach children the game. According to Nielsen's usability heuristics, the designed game had 23 unique usability problems with a mean severity of 2.29. "User control and freedom," with five usability problems, was the most frequently identified problem, and "error prevention," with a mean severity of 3.83, was the most severe problem. The results of the SLPs' evaluation also showed that the "interface quality" of the designed game obtained the highest score, with a mean score of 6.25 out of 7. Also, 100% of children stated that the game was designed beautifully, and 90% of children also liked the game. A serious game designed for children with SSDs achieved satisfactory results in usability evaluation. Therefore, this smartphone-based game can be easily used among these children to provide fun therapy sessions under the supervision of parents.

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.

The use of virtual reality for activities of daily living rehabilitation after brain injury: A scoping review

INTRODUCTION

Individuals with acquired brain injury (ABI) experience high rates of poor functional outcomes such as inability to complete activities of daily living (ADL). Occupational therapy needs to be customised to the individual's function, goals, and environment to facilitate improvement in ADLs after ABI. Virtual reality (VR) is a novel treatment approach that aims to improve skills within an individualised environment. This study aimed to review the current literature for the use of VR platforms that incorporate ADLs to improve functional outcomes after ABI.

METHODS

This review followed the six-stage framework by Arksey & O'Malley (2005). Electronic databases were searched for peer-reviewed journal articles based on inclusion and exclusion criteria.

RESULTS

One thousand and six hundred eighty articles were screened, including 413 full text articles and 13 articles were included for review. Among the 13 articles, six were RCTs and the rest were pre-post intervention studies. Studies largely used non-immersive VR platforms, which incorporated ADLs such as grocery shopping, aiming to improve functional outcomes.

CONSUMER AND COMMUNITY CONSULTATION

Consumer and community were not involved in executing this study.

CONCLUSION

This review suggests mixed results if VR is effective at treating upper limb, cognition, and ADL function after ABI. Using their clinical reasoning, occupational therapists can determine the suitability of VR for ADL rehabilitation for specific patient populations and settings. Plain Language Summary Individuals who sustain an acquired brain injury can have difficulty performing their daily activities such as, making a meal or getting dressed, because of limited function (e.g., physical and cognitive problems). To help improve their ability to complete daily activities, occupational therapy needs to be customised to the individual's function, goals, and environment. Virtual reality is a new rehabilitation approach that allows individuals to improve their function in an individualised environment. In this study, we reviewed the current studies that have used virtual reality platforms that incorporate daily activities to improve function after acquired brain injury. We searched databases and screened the titles and abstracts of 1,680 studies. Then, 413 full-text studies were screened, and 13 studies were included. Studies mostly used non-immersive platforms to practise daily activities such as, grocery shopping, aiming to improve function after acquired brain injury. This review suggests mixed results if virtual reality can effectively treat function after acquired brain injury.

Effectiveness of an Intensive, Functional, and Gamified Rehabilitation Program on Upper Limb Function in People With Stroke (EnteRtain): A Multicenter Randomized Clinical Trial

BACKGROUND1

Despite a growing interest in gaming rehabilitation for upper limb (UL) recovery post-stroke, studies investigating the effects of game-based rehabilitation incorporating functional games are lacking.

OBJECTIVE

To investigate the efficacy of an intensive, functional, gamified rehabilitation program compared to task-based training on UL motor function in acute/sub-acute stroke survivors.

METHODS

This randomized, multicenter, single-blind, clinical trial comprises 120 participants with unilateral stroke who were randomized to receive either gamified training (n = 64) using the ArmAble™ [experimental group (EG)] or task-based training (n = 56) in conjunction with conventional therapy for 2 hours per day, 6 days per week for 2 weeks, followed by UL rehabilitation for another 4 weeks at home. Primary outcomes evaluated by a blinded assessor included the Fugl-Meyer Assessment-Upper Extremity (FM-UE), and Action Research Arm Test (ARAT). Data were analyzed using a linear mixed-effect regression model.

RESULTS

The mean (standard deviation) age of the participants was 54.4 ± 11.7 years (78.1% men) in the EG and 57.7 ± 10.9 years (73.2% men) in the comparator group (CG). The median (interquartile range) time since stroke was 30.0 (54.0) days in the EG and 22.5 (45.0) days in the CG. Following the 2-week intervention, a statistically significant improvement was observed in the EG for the FM-UE [between-group mean differences (95% confidence interval): -3.9 (-6.5, -1.3); P = .003]; but not for the ARAT [-2.9 (-5.8, 0.0); P = .051]. Gains at 6 weeks were significantly greater in the EG for both FM-UE [-3.9 (-6.5, -1.3); P = .003]; and ARAT [-3.0 (-5.9, -0.0); P = .046].

CONCLUSION

Gamified rehabilitation using the ArmAble™ device has shown immediate and short-term improvement in UL function after acute/sub-acute stroke.

CLINICAL TRIALS REGISTRY NUMBER

CTRI/2020/09/027651.

The Use of Gamification in the Self-Management of Patients With Chronic Diseases: Scoping Review

BACKGROUND

Chronic disease self-management is a public health issue of worldwide concern, and gamification is an emerging strategy to improve patients' participation in chronic disease self-management. Some studies have summarized designs for the gamification of chronic disease self-management from the perspective of eHealth technology, but they have not mentioned differences in design methods, functions, and evaluation methods of gamified designs for self-management in different chronic diseases.

OBJECTIVE

This scoping review aims to synthesize the characteristics of realization forms, functions, and evaluation methods in chronic disease self-management gamification to improve self-management among the chronic disease population.

METHODS

We applied a methodological framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. As of January 7, 2023, we systematically searched 9 databases for relevant studies from January 2012 to December 2022. Related data were extracted based on the research questions. We calculated the frequencies, charted the quantitative data, and coded the extracted material for qualitative content analysis.

RESULTS

We retrieved 16,221 records, of which 70 (0.43%) met the eligibility criteria. In the included research, the target populations for gamified designs for self-management of chronic diseases included patients with stroke, cancer, diabetes, chronic obstructive pulmonary disease, coronary heart disease, obesity, and hypertension. Almost all studies mentioned technical support for gamification (68/70, 97%), mainly in the form of active video games (58/70, 83%); however, less than half of the studies mentioned the theoretical basis for gamification (31/70, 44%). There were 37 concepts or theories relevant to gamification design, most of which were in the field of psychology or were cross-disciplinary (n=33, 89%). Gamification for the self-management of chronic diseases has been widely recognized, including for promoting physical exercise and rehabilitation training (48/99, 48%), increasing initiative for symptom management (18/99, 18%), providing psychological support (14/99, 14%), improving cognitive function (12/99, 12%), and improving medication adherence (7/99, 7%). A total of 39 studies mentioned the gamification effect; however, we did not find a unified evaluation standard.

CONCLUSIONS

This scoping review focuses on gamification designs for chronic disease self-management and summarizes the realization forms and functions of gamification in self-management for different patient populations. With practice in a gamified internet-based environment, patients can not only master the knowledge and skills of self-management in fascinating scenarios but also benefit from gaming experience and make better health-related decisions in real life. It is worth noting that a comprehensive evaluation of the users as well as a personalized and targeted intervention should be developed before gamification.

Telerehabilitation in Low-Resource Settings to Improve Postural Balance in Older Adults: A Non-Inferiority Randomised Controlled Clinical Trial Protocol

Background: Several exercise methods with virtual reality devices have been used in treatments for older adults and patients with neurodegenerative diseases, although the mechanisms continue to be elucidated. The aim of this study is to establish the feasibility and effectiveness of a rehabilitation programme using low-cost virtual reality aimed at improving postural balance in older adults. It also seeks to compare low-cost virtual reality under two delivery modalities, telerehabilitation (TR) in elderly centres and face-to-face (FtF) in rehabilitation centres. Methods: The study is set up as a non-inferiority two-arm parallel triple-blind randomised controlled clinical trial. Sixteen persons aged 65 to 75-years-old will be included. Eighteen Wii therapy sessions (25-30 min) will be provided through both FtF (control group, n = 8) and TR (exposure group, n = 8), both with a Nintendo Wii balance board. Data will be collected at baseline (week 0), during the Wii therapy sessions (weeks 2, 4, and 6), and during the follow-up (weeks 8 and 10). The primary outcome will be the area of centre-of-pressure (CoP) sway; secondary outcomes will be medial-lateral and anterior-posterior velocity and standard deviation of CoP; and tertiary outcomes will be clinical measures: single-leg stand, timed up-and-go tests, Barthel Index, and Tinetti's scale. Statistical analyses will be performed using SPSS 20.00 for Windows. The trial adheres to the Declaration of Helsinki and the Chilean laws of rights and duties of the patient and research in humans. Ethical approval was obtained from the Ethics Committee of the University of Talca. Written informed consent will be obtained from participants. Discussion: In this trial, older adults from a Chilean city with a large rural and underserved population share will be included to test the feasibility and effectiveness of a rehabilitation programme using low-cost VR aimed at improving postural balance to generate evidence to support decision makers generating public health policy. Trial registration: Australian New Zeeland Clinical Trials Registration (ACTRN12621001380886).

Impact of the built environment on stroke inpatient rehabilitation

Guidance recommends that people with disability following stroke should receive rehabilitation in a dedicated stroke inpatient unit. Previous research has indicated that aspects of the built environment in inpatient settings can impact on patient wellbeing and experience. This article evaluates and discusses the findings of a recent systematic review that explores the effect of environmental and design factors on stroke rehabilitation.

A feasibility study to assess the effectiveness of Muvity: A telerehabilitation system for chronic post-stroke subjects

OBJECTIVES

To assess the feasibility of a telerehabilitation system for chronic post-stroke subjects compared to a conventional treatment.

METHODS

A feasibility cross-over analysis was conducted in ten chronic post-stroke subjects. Two randomized groups followed two eight-weeks treatments, one with the telerehabilitation system Muvity and the other following conventional therapy (in random order). Before and after each treatment, physical evaluations were performed assessing functional independence, the perceived level of pain, balance control and self-reported health status. After the study, the participants answered a short questionnaire to measure the usability of the system.

RESULTS

Four out of six subjects demonstrated better performance in ADLs (equal or higher FIM scores) and five out of six reported lower pain (VAS score) after the treatment with Muvity when compared to the treatment without. There were no clear trends in terms of balance control (Berg scale) or self-reported health status (PCS score within SF-36).

CONCLUSIONS

The results suggest that the proposed telerehabilitation system aids users to overall maintain or improve their ability to perform ADLs without increasing pain, when compared to conventional therapy. Most subjects found the use of Muvity more motivating than the conventional rehabilitation treatment. This provides initial evidence that Muvity might be an appropriate complement for the telerehabilitation of patients with physical disabilities. However, the differences observed between both treatments were not statistically significant. A clinical study with a larger sample size will be necessary to obtain more robust results.

Design of a 6-DoF Cost-effective Differential-drive based Robotic system for Upper-Limb Stroke Rehabilitation

This paper discusses the design, construction, and characteristics of a six degree of freedom (6-DoF) robotic upper limb stroke rehabilitation device. The device is primarily designed to be used by stroke survivors suffering from hemi-paresis, post stroke therapy. The proposed device is aimed to substitute upper limb exoskeletons or end-effector robotic arm based rehabilitation systems, which are generally bulky, expensive due to customized design, and are used only in clinical settings. The device is capable of aiding patients perform rehabilitation exercises involving abduction, adduction, flexion, and extension movements for the wrist, shoulder joints and flexion, extension, pronation, supination for the elbow joint. The device has a mobile base and uses differential drive principles for movement. The device provides an end-effector plate having force-sensitive resistors (FSRs) on which the patient can rest their hand. The mobile base of the rehabilitation system enables it to aid for a greater range of movements when compared to other end-effector-based upper limb rehabilitation devices. Additionally, a camera is mounted on top of the 6-DoF robotic system to enable finger tracking from a remote system using the MediaPipe framework, and measure the hand instability metric over time to assess patient's performance. Clinical relevance - The 6-DoF rehabilitation system is capable of aiding different range of motions for upper limb. The low-cost generic system is applicable for different physical personalities, enabling quick adoption for large patient populations who are in need of rehabilitation systems. The 6-DoF system is aimed towards clinical, and domestic usage by patients.

Virtual Reality in the Treatment of Adults with Chronic Low Back Pain: A Systematic Review and Meta-Analysis of Randomized Clinical Trials

Virtual reality (VR) can present advantages in the treatment of chronic low back pain. The objective of this systematic review and meta-analysis was to analyze the effectiveness of VR in chronic low back pain. This review was designed according to PRISMA and registered in PROSPERO (CRD42020222129). Four databases (PubMed, Cinahl, Scopus, Web of Science) were searched up to August 2021. Inclusion criteria were defined following PICOS recommendations. Methodological quality was assessed with the Downs and Black scale and the risk of bias with the Cochrane Risk of Bias Assessment Tool. Fourteen studies were included in the systematic review and eleven in the meta-analysis. Significant differences were found in favor of VR compared to no VR in pain intensity postintervention (11 trials; n = 569; SMD = −1.92; 95% CI = −2.73, −1.11; p < 0.00001) and followup (4 trials; n = 240; SDM = −6.34; 95% CI = −9.12, −3.56; p < 0.00001); and kinesiophobia postintervention (3 trials; n = 192; MD = −8.96; 95% CI = −17.52, −0.40; p = 0.04) and followup (2 trials; n = 149; MD = −12.04; 95% CI = −20.58, −3.49; p = 0.006). No significant differences were found in disability. In conclusion, VR can significantly reduce pain intensity and kinesiophobia in patients with chronic low back pain after the intervention and at followup. However, high heterogeneity exists and can influence the consistency of the results.