Retraining function in people with Parkinson's disease using the Microsoft kinect: game design and pilot testing

A randomised controlled pilot study of a Nintendo Ring Fit Adventure™ balance and strengthening exercise program in community-dwelling older adults with a history of falls

OBJECTIVES

This pilot study examined the feasibility, acceptability, and effects of a Nintendo Ring Fit Adventure™-based balance and muscle strengthening exercise program in community-dwelling older adults with a history of falls.

METHODS

Older adults who have had at least one fall in the past year were randomly assigned to an experimental (n = 21) or control group (n = 21). The experimental group performed 16 exercise sessions in total, lasting 60 min each, twice a week for 8 weeks, whereas the control group received usual care. Feasibility was evaluated based on the scores of participants in the exercises. Acceptance was evaluated using a customised questionnaire examining participants' self-perceived enjoyment, feasibility and improvements. Clinical outcomes including balance (Mini-BESTest), lower limb muscle strength (Five-Time Sit-to-Stand test), mobility (Timed-Up and Go test), dual-task ability (Timed-Up and Go test-Dual Task), fear of falling (Icon-FES) and executive function (Color Trails Test) were evaluated at baseline and 8 weeks.

RESULTS

Thirty-one participants (74%) finished the 8-week assessment. The experimental group significantly improved their scores in six out of eight exercises (all p < .031). The mean scores of the self-perceived enjoyment, feasibility and improvement domains of the acceptability questionnaire were 3.46 ± .53, 3.08 ± .59, and 3.47 ± .57 respectively. A significant improvement in the anticipatory subscore of the Mini-BESTest was found in the experimental group compared to the control group (p = .02; Partial eta squared = .14).

CONCLUSIONS

The Nintendo Ring Fit Adventure™-based exercise program was feasible, acceptable, and potentially effective in community-dwelling older adults with a history of falls.

The Flow State Scale for Rehabilitation Tasks: A New Flow Experience Questionnaire for Stroke Patients

IMPORTANCE

Flow can be described as a subjective state that people report when they fully engage in an activity and experience pleasure, satisfaction, and enjoyment. Flow experiences are measured to determine the extent to which patients engage in therapy activities. Several flow questionnaires are used in neurorehabilitation. However, none have been validated for patients with (sub)acute stroke.

OBJECTIVE

To develop and validate a new flow questionnaire for patients with (sub)acute stroke.

DESIGN

Single-center prospective cohort study.

SETTING

Neurorehabilitation unit of the Neurocenter of the Luzerner Kantonsspital in Lucerne, Switzerland.

PARTICIPANTS

Fifty patients with (sub)acute stroke.

OUTCOMES AND MEASURES

Development of the Flow State Scale for Rehabilitation Tasks (FSSRT) and determination of the psychometric properties of the FSSRT (internal consistency, test-retest reliability, structural and construct validity) in (sub)acute stroke patients.

RESULTS

The FSSRT showed good internal consistency and excellent test-retest reliability. Composed of four components-concentration, pleasure, movement control, and absorption-the FSSRT correlated significantly negatively with the Hospital Anxiety and Depression Scale, indicating good divergent validity.

CONCLUSIONS AND RELEVANCE

The FSSRT is a reliable and valid questionnaire measuring flow experience in patients with (sub)acute stroke. This questionnaire can be easily used in occupational therapy as well as in physical therapy and gives therapists important information about the flow experience of patients during therapy to adjust the therapy accordingly. Plain-Language Summary: Measuring flow experience, or the extent to which patients engage in therapy activities, in the context of occupational therapy and physical therapy is a new approach. This study confirmed that the Flow State Scale for Rehabilitation Tasks questionnaire is reliable and valid for measuring the flow experience of patients after (sub)acute stroke. Occupational therapists and physical therapists can use the FSSRT to optimally adjust the therapy program and increase patient engagement during therapy.

Effectiveness of Virtual Reality Therapy on Balance and Gait in the Elderly: A Systematic Review

Virtual reality (VR) therapies are presently utilized to treat physical and cognitive impairments among elderly people. This systematic review aims to collect the most recent evidence on the effectiveness of VR in improving balance and gait among healthy elderly individuals, in comparison with other therapies. A literature search was conducted using the PubMed, SCOPUS, PEDro, and WoS databases, by selecting randomized clinical trials that evaluated balance, both static and dynamic, as well as gait in a population of healthy older adults who underwent virtual reality therapy. The methodological quality of the studies was assessed using the PEDro scale. After eligibility criteria were applied and duplicates were removed, 20 studies were selected out of 1705 initially identified. The present systematic review concludes that virtual reality therapy is more effective than minimal intervention or usual care in enhancing static balance, dynamic balance, and gait in healthy elderly individuals. Moreover, virtual reality therapy yields better outcomes compared to traditional balance training and physical exercise in improving balance and gait in this demographic. However, both methods have shown effectiveness.

Successful implementation of technology in the management of Parkinson's disease: Barriers and facilitators

Background

Parkinson's disease (PD) is a progressive neurodegenerative disease with a fast increasing prevalence. Several pharmacological and non-pharmacological interventions are available to alleviate symptoms. Technology can be used to improve the efficiency, accessibility and feasibility of these treatments. Although many technologies are available, only few are actually implemented in daily clinical practice.

Aim

Here, we study the barriers and facilitators, as experienced by patients, caregivers and/or healthcare providers, to successful implement technology for PD management.

Methods

We performed a systematic literature search in the PubMed and Embase databases until June 2022. Two independent raters screened the titles, abstracts and full texts on: 1) people with PD; 2) using technology for disease management; 3) qualitative research methods providing patients', caregivers and/or healthcare providers' perspective, and; 4) full text available in English or Dutch. Case studies, reviews and conference abstracts were excluded.

Results

We found 5420 unique articles of which 34 were included in this study. Five categories were made: cueing (n = 3), exergaming (n = 3), remote monitoring using wearable sensors (n = 10), telerehabilitation (n = 8) and remote consultation (n = 10). The main barriers reported across categories were unfamiliarity with technology, high costs, technical issues and (motor) symptoms hampering the use of some technologies. Facilitators included good usability, experiencing beneficial effects and feeling safe whilst using the technology.

Conclusion

Although only few articles presented a qualitative evaluation of technologies, we found some important barriers and facilitators that may help to bridge the gap between the fast developing technological world and actual implementation in day-to-day living with PD.

Virtual Reality for Motor and Cognitive Rehabilitation

Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of 'active' ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson's Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as 'active ingredients' of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.

Effectiveness of home-based rehabilitation using active video games on quality of life, cognitive and motor functions in people with Parkinson's disease: a systematic review

PURPOSE

We summarized the effectiveness of home-based active video game interventions on physical and cognitive functions, as well as quality of life in adults with Parkinson's disease. We also assessed the feasibility, safety, adherence, and retention of benefits of these interventions.

METHOD

We searched studies in eight databases from 1st March to 30th November 2020. Two authors independently performed the selection, data extraction and risk of bias evaluation (PROSPERO ID: CRD42020178138).

RESULTS

Nine studies were included in this systematic review (412 participants). All in all, home-based active video games were found effective in improving gait and balance functions in people with Parkinson's disease, equivalent to usual care and conventional therapy. No conclusion can be drawn on cognition and quality of life. Home-based active video games seemed feasible, safe, and were enjoyed by people with Parkinson's disease. The optimal dose, the need for supervision and the retention of benefits of these interventions are still to be determined. These results should be interpreted carefully, considering the limited number of included studies and their small sample sizes, the widespread heterogeneity of included studies and their medium average methodological quality.

CONCLUSION

Future research should focus on the effects of home-based active video games on impairments specific to Parkinson's disease, such as falls, freezing of gait and attention, as well as the dose, need for supervision and retention of the benefits of these interventions.IMPLICATIONS FOR REHABILITATIONHome-based active video games are effective in improving motor functions in people with PD.No conclusion can be drawn regarding cognition in people with PD.No conclusion can be drawn regarding quality of life in people with PD.Home-based active video games seem feasible and safe, and are enjoyed by people with PD.The dose, need for control and retention of the benefits still need to be determined.

A New Architecture for Customizable Exergames: User Evaluation for Different Neuromuscular Disorders

This paper presents a modular approach to generic exergame design that combines custom physical exercises in a meaningful and motivating story. This aims to provide a tool that can be individually tailored and adapted to people with different needs, making it applicable to different diseases and states of disease. The game is based on motion capturing and integrates four example exercises that can be configured via our therapeutic web platform “Blexer-med”. To prove the feasibility for a wide range of different users, evaluation tests were performed on 14 patients with various types and degrees of neuromuscular disorders, classified into three groups based on strength and autonomy. The users were free to choose their schedule and frequency. The game scores and three surveys (before, during, and after the intervention) showed similar experiences for all groups, with the most vulnerable having the most fun and satisfaction. The players were motivated by the story and by achieving high scores. The average usage time was 2.5 times per week, 20 min per session. The pure exercise time was about half of the game time. The concept has proven feasible and forms a reasonable basis for further developments. The full 3D exercise needs further fine-tuning to enhance the fun and motivation.

Usability of Two New Interactive Game Sensor-Based Hand Training Devices in Parkinson's Disease

This pilot cross-sectional study aimed to evaluate the usability of two new interactive game sensor-based hand devices (GripAble and Smart Sensor Egg) in both healthy adults as well as in persons with Parkinson's Disease (PD). Eight healthy adults and eight persons with PD participated in this study. Besides a standardised usability measure, the state of flow after one training session and the effect of cognitive abilities on flow were evaluated. High system usability scores (SUS) were obtained both in healthy participants (72.5, IQR = 64.375-90, GripAble) as well as persons with PD (77.5, IQR = 70-80.625, GripAble; 77.5, IQR = 75-82.5, Smart Sensor Egg). Similarly, high FSSOT scores were achieved after one training session (42.5, IQR = 39.75-50, GripAble; 50, IQR = 47-50, Smart Sensor Egg; maximum score 55). Across both groups, FSSOT scores correlated significantly with SUS scores (r = 0.52, p = 0.039). Finally, MoCA did not correlate significantly with FSSOT scores (r = 0.02, p = 0.9). The present study shows high usability for both interactive game sensor-based hand training devices, for persons with PD and healthy participants.

A Literature Review of High-Tech Physiotherapy Interventions in the Elderly with Neurological Disorders

Neurological physiotherapy adopts a problem-based approach for each patient as determined by a thorough evaluation of the patient’s physical and mental well-being. Τhis work aims to provide a literature review of physical therapy interventions in the elderly with neurological diseases (NDs) and discuss physiotherapy procedures and methods that utilize cutting-edge technologies for which clinical studies are available. Hence, the review focuses on acute NDs (stroke), deteriorating NDs (Parkinson’s disease), and age-related cognitive impairment. The most used physiotherapy procedures on which clinical data are available are balance and gait training (robot-assisted or not), occupational therapy, classical physiotherapy, walking and treadmill training, and upper limb robot-assisted therapy. Respectively, the most often-used equipment are types of treadmills, robotic-assisted equipment (Lokomat^® and Gait Trainer GT1), and portable walkway systems (GAITRite^®), along with state-of-the-art technologies of virtual reality, virtual assistants, and smartphones. The findings of this work summarize the core standard tools and procedures, but more importantly, provide a glimpse of the new era in physiotherapy with the utilization of innovative equipment tools for advanced patient monitoring and empowerment.

Design of a wearable vibrotactile stimulation device for individuals with upper-limb hemiparesis and spasticity

Vibratory stimulation may improve post-stroke symptoms such as spasticity; however, current studies are limited by the large, clinic-based apparatus used to apply this stimulation. A wearable device could provide vibratory stimulation in a mobile form, enabling further study of this technique. An initial device, the vibrotactile stimulation (VTS) Glove, was deployed in an eight-week clinical study in which sixteen individuals with stroke used the device for several hours daily. Participants reported wearing the glove during activities such as church, social events, and dining out. However, 69% of participants struggled to extend or insert their fingers to don the device. In a follow-up study, eight individuals with stroke evaluated new VTS device prototypes in a three-round iterative design study with the aims of creating the next generation of VTS devices and understanding features that influence interaction with a wearable device by individuals with impaired upper-limb function. Interviews and interaction tasks were used to define actionable design revisions between each round of evaluation. Our analysis identified six new themes from participants regarding device designs: hand supination is challenging, separate finger attachments inhibit fit and use, fingers may be flexed or open, fabric coverage impacts comfort, a reduced concern for social comfort, and the affected hand is infrequently used. Straps that wrap around the arm and fixtures on the anterior arm were other challenging features. We discuss potential accommodations for these challenges, as well as social comfort. New VTS device designs are presented and were donned in an average time of 48 seconds.

Evaluation of a Digitally Guided Self-Rehabilitation Device Coupled With Telerehabilitation Monitoring in Patients With Parkinson Disease (TELEP@RK): Open, Prospective Observational Study

Background

Parkinson disease is a neurodegenerative disease causing a progressive loss of autonomy. This requires long-term rehabilitation care. Currently, new technologies are being developed for use in daily life, and there is a progressive implementation of telerehabilitation.

Objective

The aim of this study (the TELEP@RK study) is to evaluate the uses of a digital self-rehabilitation device in patients with Parkinson disease and their independent physiotherapists on the scale of a health territory.

Methods

A total of 10 independent physiotherapists and 31 patients with Parkinson disease were followed for 1 year to evaluate the use of a telerehabilitation tool (digital tablet and inertial sensor) via questionnaires of the Unified Theory of Acceptance and Use of Technology (UTAUT). The questionnaires were submitted to participants at 0, 2, and 12 months from the start of follow-up. The averages of the scores of the different determinants and constructs of the UTAUT questionnaires were compared at the different follow-up times.

Results

Among professionals, the averages of the various determinants were generally high at the beginning of the study with an average (out of 5) performance expectancy of 4.19, effort expectancy of 3.88, social influence of 3.95, facilitating conditions of 4, and intention to use of 3.97. These averages decreased over time.

Conclusions

Acceptability, acceptance, and appropriation of the tool were very high among the physiotherapists as well as the patients, despite the tool’s lack of evolution during the study. In the current health care context, these results allow us to envision a new organization of the care pathway for patients with chronic diseases, with the increased use of new technologies associated with telecare.

Real-Time Limb Motion Tracking with a Single IMU Sensor for Physical Therapy Exercises

Limb exercises are common in physical therapy to improve range of motion (RoM), strength, and flexibility of the arm/leg. To improve therapy outcomes and reduce cost, motion tracking systems have been used to monitor the user's movements when performing the exercises and provide guidance. Traditional motion tracking systems are based on either cameras or inertial measurement unit (IMU) sensors. Camera-based systems face problems caused by occlusion and lighting. Traditional IMU-based systems require at least two IMU sensors to track the motion of the entire limb, which is not convenient for use. In this paper, we propose a novel limb motion tracking system that uses a single 9-axis IMU sensor that is worn on the distal end joint of the limb (i.e., wrist for the arm or ankle for the leg). Limb motion tracking using a single IMU sensor is a challenging problem because 1) the noisy IMU data will cause drift problem when estimating position from the acceleration data, 2) the single IMU sensor measures the motion of only one joint but the limb motion consists of motion from multiple joints. To solve these problems, we propose a recurrent neural network (RNN) model to estimate the 3D positions of the distal end joint as well as the other joints of the limb (e.g., elbow or knee) from the noisy IMU data in real time. Our proposed approach achieves high accuracy with a median error of 7.2/7.1 cm for the wrist/elbow joint in leave-one-subject-out cross validation when tracking the arm motion, outperforming the state-of-the-art approach by more than 10%. In addition, the proposed model is lightweight, enabling real-time applications on mobile devices.Clinical relevance- This work has great potential to improve limb exercises monitoring and RoM measurement in home-based physical therapy. It is also cost effective and can be made available widely for immediate application.

Getting into a "Flow" state: a systematic review of flow experience in neurological diseases

BACKGROUND

Flow is a subjective psychological state that people report when they are fully involved in an activity to the point of forgetting time and their surrounding except the activity itself. Being in flow during physical/cognitive rehabilitation may have a considerable impact on functional outcome, especially when patients with neurological diseases engage in exercises using robotics, virtual/augmented reality, or serious games on tablets/computer. When developing new therapy games, measuring flow experience can indicate whether the game motivates one to train. The purpose of this study was to identify and systematically review current literature on flow experience assessed in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson's disease. Additionally, we critically appraised, compared and summarized the measurement properties of self-reported flow questionnaires used in neurorehabilitation setting.

DESIGN

A systematic review using PRISMA and COSMIN guidelines.

METHODS

MEDLINE Ovid, EMBASE Ovid, CINAHL EBSCO, SCOPUS were searched. Inclusion criteria were (1) peer-reviewed studies that (2) focused on the investigation of flow experience in (3) patients with neurological diseases (i.e., stroke, traumatic brain injury, multiple sclerosis and/or Parkinson's disease). A qualitative data synthesis was performed to present the measurement properties of the used flow questionnaires.

RESULTS

Ten studies out of 911 records met the inclusion criteria. Seven studies measured flow in the context of serious games in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson's disease. Three studies assessed flow in other activities than gaming (song-writing intervention and activities of daily living). Six different flow questionnaires were used, all of which were originally validated in healthy people. None of the studies presented psychometric data in their respective research population.

CONCLUSION

The present review indicates that flow experience is increasingly measured in the physical/cognitive rehabilitation setting in patients with neurological diseases. However, psychometric properties of used flow questionnaires are lacking. For exergame developers working in the field of physical/cognitive rehabilitation in patients with neurological diseases, a valid flow questionnaire can help to further optimize the content of the games so that optimal engagement can occur during the gameplay. Whether flow experiences can ultimately have positive effects on physical/cognitive parameters needs further study.

A Solution for the Remote Care of Frail Elderly Individuals via Exergames

Internet of Things (IoT) solutions are a concrete answer to many needs in the healthcare framework since they enable remote support for patients and foster continuity of care. Currently, frail elderly people are among end users who most need and would benefit from IoT solutions from both a social and a healthcare point of view. Indeed, IoT technologies can provide a set of services to monitor the healthcare of the elderly or support them in order to reduce the risk of injuries, and preserve their motor and cognitive abilities. The main feature of IoT solutions for the elderly population is ease of use. Indeed, to fully exploit the potential of an IoT solution, patients should be able to autonomously deal with it. The remote-monitoring validation engineering system (ReMoVES) described here is an IoT solution that caters to the specific needs of frail elderly individuals. Its architecture was designed for use at rehabilitation centers and at patients' homes. The system is user-friendly and comfortably usable by persons who are not familiar with technology. In addition, exergames enhance patient engagement in order to curb therapy abandonment. Along with the technical presentation of the solution, a real-life scenario application is described referring to sit-to-stand activity.

Effects of Kinect Video Game Training on Lower Extremity Motor Function, Balance, and Gait in Adolescents with Spastic Diplegia Cerebral Palsy: A Pilot Randomized Controlled Trial

The Kinect video game (KVG) has received attention as an intervention method for cerebral palsy (CP). However, evidence remains limited.

PURPOSE

To investigate the effects of training using Xbox Kinect on lower extremity motor function, balance, and gait in adolescents with spastic diplegia CP.

METHODS

This study was a pilot randomized controlled trial. Ten participants were randomly allocated to either the KVG training group (n = 5) or the conventional training (CT) group (n = 5). The Selective Control Assessment of the Lower Extremity (SCALE) tool, Pediatric Balance Scale (PBS), and GAITRite were used for the outcome measurements.

RESULTS

In the comparison between the groups, the KVG group showed significant improvements in all the items in the SCALE (except for right hip abduction) and PBS score as compared with the CT group.

CONCLUSIONS

KVG training might be an effective intervention for the rehabilitation of adolescents with spastic diplegia CP.

Instrumental Assessment of Stepping in Place Captures Clinically Relevant Motor Symptoms of Parkinson's Disease

Fluctuations of motor symptoms make clinical assessment in Parkinson's disease a complex task. New technologies aim to quantify motor symptoms, and their remote application holds potential for a closer monitoring of treatment effects. The focus of this study was to explore the potential of a stepping in place task using RGB-Depth (RGBD) camera technology to assess motor symptoms of people with Parkinson's disease. In total, 25 persons performed a 40 s stepping in place task in front of a single RGBD camera (Kinect for Xbox One) in up to two different therapeutic states. Eight kinematic parameters were derived from knee movements to describe features of hypokinesia, asymmetry, and arrhythmicity of stepping. To explore their potential clinical utility, these parameters were analyzed for their Spearman's Rho rank correlation to clinical ratings, and for intraindividual changes between treatment conditions using standard response mean and paired t-test. Test performance not only differed between ON and OFF treatment conditions, but showed moderate correlations to clinical ratings, specifically ratings of postural instability (pull test). Furthermore, the test elicited freezing in some subjects. Results suggest that this single standardized motor task is a promising candidate to assess an array of relevant motor symptoms of Parkinson's disease. The simple technical test setup would allow future use by patients themselves.

Meaningful change: Defining the interpretability of changes in endpoints derived from interactive and mHealth technologies in healthcare and clinical research

Immersive, interactive and mHealth technologies are increasingly being used in clinical research, healthcare and rehabilitation solutions. Leveraging technology solutions to derive new and novel clinical outcome measures is important to the ongoing assessment of clinical interventions. While demonstrating statistically significant changes is an important element of intervention assessment, understanding whether changes detected reflect changes of a magnitude that are considered meaningful to patients is equally important. We describe methodologies used to determine meaningful change and recommend that these techniques are routinely included in the development and testing of clinical assessment and rehabilitation technology solutions.

The Practical Work of Ensuring Effective Use of Serious Games in a Rehabilitation Clinic: A Qualitative Study

BACKGROUND

Many rehabilitation clinics adopted serious games to support their physiotherapy sessions. Serious games can monitor and provide feedback on exercises and are expected to improve therapy and help professionals deal with more patients. However, there is little understanding of the impacts of serious games on the actual work of physiotherapists.

OBJECTIVE

This study aimed to understand the impact of an electromyography-based serious game on the practical work of physiotherapists.

METHODS

This study used observation sessions in an outpatient rehabilitation clinic that recently started using a serious game based on electromyography sensors. In total, 44 observation sessions were performed, involving 3 physiotherapists and 22 patients. Observation sessions were documented by audio recordings or fieldnotes and were analyzed for themes with thematic analysis.

RESULTS

The findings of this study showed that physiotherapists played an important role in enabling the serious game to work. Physiotherapists briefed patients, calibrated the system, prescribed exercises, and supported patients while they played the serious game, all of which amounted to relevant labor.

CONCLUSIONS

The results of this work challenge the idea that serious games reduce the work of physiotherapists and call for an overall analysis of the different impacts a serious game can have. Adopting a serious game that creates more work can be entirely acceptable, provided the clinical outcomes or other advantages enabled by the serious game are strong; however, those impacts will have to be assessed on a case-by-case basis. Moreover, this work motivates the technology development community to better investigate physiotherapists and their context, offering implications for technology design.

The role of virtual reality on outcomes in rehabilitation of Parkinson's disease: meta-analysis and systematic review in 1031 participants

Introduction

Parkinson’s disease (PD) is managed primarily by dopamine agonists and physiotherapy while virtual reality (VR) has emerged recently as a complementary method. The present study reviewed the effectiveness of VR in rehabilitation of patients with PD.

Methods

Literature search up to June 2019 identified ten studies (n = 343 participants) suitable for meta-analysis and 27 studies (n = 688 participants) for systematic review. Standard mean difference (SMD) and 95% confidence intervals (CI) were calculated using a random effects model.

Results

In meta-analysis, compared with active rehabilitation intervention, VR training led to greater improvement of stride length, SMD = 0.70 (95%CI = 0.32–1.08, p = 0.0003), and was as effective for gait speed, balance and co-ordination, cognitive function and mental health, quality of life and activities of daily living. Compared with passive rehabilitation intervention, VR had greater effects on balance: SMD = 1.02 (95%CI = 0.38–1.65, p = 0.002). Results from single randomised controlled trials showed that VR training was better than passive rehabilitation intervention for improving gait speed SMD = 1.43 (95%CI = 0.51–2.34, p = 0.002), stride length SMD = 1.27 (95%CI = 0.38–2.16, p = 0.005) and activities of daily living SMD = 0.96 (95%CI = 0.02–1.89). Systematic review showed that VR training significantly (p < 0.05) improved motor function, balance and co-ordination, cognitive function and mental health, and quality of life and activities of daily living.

Conclusion

VR used in rehabilitation for patients with PD improves a number of outcomes and may be considered for routine use in rehabilitation.

Electronic supplementary material

The online version of this article (10.1007/s10072-019-04144-3) contains supplementary material, which is available to authorized users.

A Framework for Interpretable Full-Body Kinematic Description Using Geometric and Functional Analysis

Rapid advances in cost-effective and non-invasive depth sensors, and the development of reliable and real-time 3D skeletal data estimation algorithms, have opened up a new application area in computer vision - statistical analysis of human kinematic data for fast, automated assessment of body movements. These assessments can play important roles in sports, medical diagnosis, physical therapy, elderly monitoring and related applications. This paper develops a comprehensive geometric framework for quantification and statistical evaluation of kinematic features. The key idea is to avoid analysis of individual joints, as is the current paradigm, and represent movements as temporal evolutions, or trajectories, on shape space of full body skeletons. This allows metrics with appropriate invariance properties to be imposed on these trajectories and leads to definitions of higher-level features, such as spatial symmetry (sS), temporal symmetry (tS), action's velocity (Vl) and body's balance (Bl), during performance of an action. These features exploit skeletal symmetries in space and time, and capture motion cadence to naturally quantify motions of individual subjects. The study of these features as functional data allows us to formulate certain hypothesis tests in feature space. This, in turn, leads to validation of existing assumptions and discoveries of new relationships between kinematics and demographic factors, such as age, gender, and athletic training. We use the clinically validated K3Da kinect dataset to illustrate these ideas, and hope these tools will lead to discovery of new relationships between full-body kinematic features and demographic, health, and wellness factors that are clinically relevant.

Towards On-Demand Virtual Physical Therapist: Machine Learning-Based Patient Action Understanding, Assessment and Task Recommendation

In this paper, we propose a machine learning-based virtual physical therapist (PT) system to enable personalized remote training for patients with Parkinson's disease (PD). Three physical therapy tasks with multiple difficulty levels are selected to help patients with PD improve balance and mobility. Patients' movements are captured by a Kinect sensor. Criteria for each task are carefully designed by our PT co-author such that the patient's performance can be evaluated in an automated manner. Given the patient's motion data, we propose a two-phase human action understanding algorithm TPHAU to understand the patient's movements, and an error identification model to identify the patient's movement errors. To enable automated task recommendation, a machine learning-based model is trained from real patient and PT data to provide accurate, personalized, and timely task update recommendation for patients with PD, thereby emulating a real PT's behavior. Real patient data have been collected in the clinic to train the models. Experiments show that the proposed methods achieve high accuracy in patient action understanding, error identification and task recommendation. The proposed virtual PT system has the potential of enabling on-demand virtual care and significantly reducing cost for both patients and care providers.

Frailty Level Monitoring and Analysis after a Pilot Six-Week Randomized Controlled Clinical Trial Using the FRED Exergame Including Biofeedback Supervision in an Elderly Day Care Centre

Background: Frailty is a status of extreme vulnerability to endogenous and exogenous stressors exposing the individual to a higher risk of negative health-related outcomes. Exercise using interactive videos, known as exergames, is being increasingly used to increase physical activity by improving health and the physical function in elderly adults. The purpose of this study is to ascertain the reduction in the degree of frailty, the degree of independence in activities of daily living, the perception of one's state of health, safety and cardiac healthiness by the exercise done using FRED over a 6-week period in elderly day care centre. Material and Methods: Frail volunteers >65 years of age, with a score of <10 points (SPPB), took part in the study. A study group and a control group of 20 participants respectively were obtained. Following randomisation, the study group (20) took part in 18 sessions in total over 6 months, and biofeedback was recorded in each session. Results: After 6 weeks, 100% of patients from the control group continued evidencing frailty risk, whereas only 5% of patients from the study group did so, with p < 0.001 statistical significance. In the case of the EQ-VAS, the control group worsened (-12.63 points) whereas the study group improved (12.05 points). The Barthel Index showed an improvement in the study group after 6 weeks, with statistically significant evidence and a value of p < 0.003906. Safety compliance with the physical activity exceeded 87% and even improved as the days went by. Discussion: Our results stand out from those obtained by other authors in that FRED is an ad hoc-designed exergame, significantly reduced the presence and severity of frailty in a sample of sedentary elders, thus potentially modifying their risk profile. It in turn improves the degree of independence in activities of daily living and the perception of one's state of health, proving to be a safe and cardiac healthy exercise. Conclusions: The study undertaken confirms the fact that the FRED game proves to be a valid technological solution for reducing frailty risk. Based on the study conducted, the exergame may be considered an effective, safe and entertaining alternative.

Recent advances in rehabilitation for Parkinson's Disease with Exergames: A Systematic Review

OBJECTIVE

The goal of this contribution is to gather and to critically analyze recent evidence regarding the potential of exergaming for Parkinson's disease (PD) rehabilitation and to provide an up-to-date analysis of the current state of studies on exergame-based therapy in PD patients.

METHODS

We performed our search based on the conclusions of a previous systematic review published in 2014. Inclusion criteria were articles published in the indexed databases Pubmed, Scopus, Sciencedirect, IEEE and Cochrane published since January 1, 2014. Exclusion criteria were papers with a target group other than PD patients exclusively, or contributions not based on exergames. Sixty-four publications out of 525 matches were selected.

RESULTS

The analysis of the 64 selected publications confirmed the putative improvement in motor skills suggested by the results of the previous review. The reliability and safety of both Microsoft Kinect and Wii Balance Board in the proposed scenarios was further confirmed by several recent studies. Clinical trials present better (n = 5) or similar (n = 3) results than control groups (traditional rehabilitation or regular exercise) in motor (TUG, BBS) and cognitive (attention, alertness, working memory, executive function), thus emphasizing the potential of exergames in PD. Pilot studies (n = 11) stated the safety and feasibility of both Microsoft Kinect and Wii Balance Board, potentially in home scenarios as well. Technical papers (n = 30) stated the reliability of balance and gait data captured by both devices. Related meta-analyses and systematic reviews (n = 15) further support these statements, generally citing the need for adaptation to patient's skills and new input devices and sensors as identified gaps.

CONCLUSION

Recent evidence indicates exergame-based therapy has been widely proven to be feasible, safe, and at least as effective as traditional PD rehabilitation. Further insight into new sensors, best practices and different cognitive stadiums of PD (such as PD with Mild Cognitive Impairment), as well as task specificity, are required. Also, studies linking game parameters and results with traditional assessment methods, such as UPDRS scores, are required. Outcomes for randomized controlled trials (RCTs) should be standardized, and follow-up studies are required, particularly for motor outcomes.

Using Kinect to classify Parkinson's disease stages related to severity of gait impairment

BACKGROUND

Parkinson's Disease (PD) is a chronic neurodegenerative disease associated with motor problems such as gait impairment. Different systems based on 3D cameras, accelerometers or gyroscopes have been used in related works in order to study gait disturbances in PD. Kinect Ⓡ has also been used to build these kinds of systems, but contradictory results have been reported: some works conclude that Kinect does not provide an accurate method of measuring gait kinematics variables, but others, on the contrary, report good accuracy results.

METHODS

In this work, we have built a Kinect-based system that can distinguish between different PD stages, and have performed a clinical study with 30 patients suffering from PD belonging to three groups: early PD patients without axial impairment, more evolved PD patients with higher gait impairment but without Freezing of Gait (FoG), and patients with advanced PD and FoG. Those patients were recorded by two Kinect devices when they were walking in a hospital corridor. The datasets obtained from the Kinect were preprocessed, 115 features identified, some methods were applied to select the relevant features (correlation based feature selection, information gain, and consistency subset evaluation), and different classification methods (decision trees, Bayesian networks, neural networks and K-nearest neighbours classifiers) were evaluated with the goal of finding the most accurate method for PD stage classification.

RESULTS

The classifier that provided the best results is a particular case of a Bayesian Network classifier (similar to a Naïve Bayesian classifier) built from a set of 7 relevant features selected by the correlation-based on feature selection method. The accuracy obtained for that classifier using 10-fold cross validation is 93.40%. The relevant features are related to left shin angles, left humerus angles, frontal and lateral bents, left forearm angles and the number of steps during spin.

CONCLUSIONS

In this paper, it is shown that using Kinect is adequate to build a inexpensive and comfortable system that classifies PD into three different stages related to FoG. Compared to the results of previous works, the obtained accuracy (93.40%) can be considered high. The relevant features for the classifier are: a) movement and position of the left arm, b) trunk position for slightly displaced walking sequences, and c) left shin angle, for straight walking sequences. However, we have obtained a better accuracy (96.23%) for a classifier that only uses features extracted from slightly displaced walking steps and spin walking steps. Finally, the obtained set of relevant features may lead to new rehabilitation therapies for PD patients with gait problems.

Exergame Experience of Young and Old Individuals Under Different Difficulty Adjustment Methods

In this work, we compare the exergaming experience of young and old individuals under four difficulty adjustment methods. Physical inactivity is a leading cause of numerous health conditions including heart diseases, diabetes, cancer, and reduced life expectancy. Committing to regular physical exercise is a simple non-pharmaceutical preventive measure for maintaining good health and sustaining quality of life. Incorporating exercise into games, studies frequently used exergames as an intervention tool over the last decades to improve physical functions and to increase adherence to exercise. While task difficulty optimization is crucial to exergame design, researchers consistently overlooked age as an element which can significantly influence the nature of end results. We use the Flow State Scale to analyze the mental state of young and old individuals to compare constant difficulty with ramping, performance-based, and biofeedback-based difficulty adjustments. Our results indicate that old individuals are less likely to experience flow compared to young under the same difficulty adjustment methods. Further investigation revealed that old individuals are likely to experience flow under ramping and biofeedback-based difficulty adjustments whereas performance-based adjustments were only feasible for young.

Effects of virtual rehabilitation on cognition and quality of life of patients with Parkinson’s disease

Abstract Introduction: Parkinson’s disease causes progressive decline of motor and cognitive functions leading to a decrease in the independence and quality of life of people affected. Training through virtual reality is proving effective, as it promotes cognitive and motor stimuli, which can be beneficial for these individuals, improving their quality of life. Objective: To analyze the effects of virtual reality on the cognition and quality of life of patients with Parkinson’s disease. Methods: A total of 11 individuals with a mean age of 65 (9.6) years classified in stages 1 to 3 of the Hoehn and Yahr Scale participated in this study. The subjects participated in fourteen sessions lasting one hour, twice a week for seven weeks in which they practiced four games of Kinect Adventures!. They were evaluated before, immediately after the intervention and 30 days after the intervention. Cognition was assessed using the Montreal Cognitive Scale (MoCA) and quality of life was assessed using the Parkinson’s Disease Questionnaire (PDQ-39). Results: Only PDQ-39 activities from the domain of daily living demonstrated a statistically significant improvement. The MoCA scores, in general, remained the same. Conclusion: Although virtual reality training promoted improvement in PDQ-39 activities in the daily life domain, it was not effective in the other domains assessed for quality of life and cognition.

Characteristics, Usability, and Users Experience of a System Combining Cognitive and Physical Therapy in a Virtual Environment: Positive Bike

We present the architecture and usability evaluation of virtual reality system-"Positive Bike"-designed for improving cognitive and motor conditions in frail elderly patients. The system consists of a cycle-ergometer integrated in an immersive virtual reality system (CAVE) which allows combining motor and cognitive exercises according to a "dual-task" paradigm. We tested the usability and user's experience of the prototype in a pilot evaluation study that involved five elderly patients. The prototype was tested in one-session training to understand the limitations and areas for improvement of our system. The evaluation consisted in (i) usability assessment using the system usability scale; (ii) evaluation of user's engagement using the flow state scale; and (iii) expert evaluation involving interviews with domain experts. Results showed a good usability, both for system usability scale and the semi-structured interview. The level of flow (i.e., enjoyment with the task at hand) measured using the short flow state scale, was also high. Analysis of semi-structured interview carried out with domain experts provided further indications to improve the system. Overall, these findings show that, despite some limitations, the system is usable and provides an enjoyable user's experience.

Feasibility of Kinect-Based Games for Balance Rehabilitation: A Case Study

We aimed at determining the effects of prototype games on older adults attending a rehabilitation program in an elderly house in this work. We conducted an initial case study where two participants underwent a 5-week intervention. Feasibility was assessed by examining recruitment, adherence, and safety. The Tinetti balance test was used as pretest and posttest assessments. Results show that adherence was very high and no adverse effects were registered during the sessions. The included participants also reported enjoyment during the playtime and exhibited improvements in Tinetti scores. The findings suggest that game-based rehabilitation can be useful for improving balance in elderly people and can be incorporated in a fall prevention program.

A Telerehabilitation System for the Selection, Evaluation and Remote Management of Therapies

Telerehabilitation systems that support physical therapy sessions anywhere can help save healthcare costs while also improving the quality of life of the users that need rehabilitation. The main contribution of this paper is to present, as a whole, all the features supported by the innovative Kinect-based Telerehabilitation System (KiReS). In addition to the functionalities provided by current systems, it handles two new ones that could be incorporated into them, in order to give a step forward towards a new generation of telerehabilitation systems. The knowledge extraction functionality handles knowledge about the physical therapy record of patients and treatment protocols described in an ontology, named TrhOnt, to select the adequate exercises for the rehabilitation of patients. The teleimmersion functionality provides a convenient, effective and user-friendly experience when performing the telerehabilitation, through a two-way real-time multimedia communication. The ontology contains about 2300 classes and 100 properties, and the system allows a reliable transmission of Kinect video depth, audio and skeleton data, being able to adapt to various network conditions. Moreover, the system has been tested with patients who suffered from shoulder disorders or total hip replacement.

Utilising the Intel RealSense Camera for Measuring Health Outcomes in Clinical Research

Applications utilising 3D Camera technologies for the measurement of health outcomes in the health and wellness sector continues to expand. The Intel® RealSense™ is one of the leading 3D depth sensing cameras currently available on the market and aligns itself for use in many applications, including robotics, automation, and medical systems. One of the most prominent areas is the production of interactive solutions for rehabilitation which includes gait analysis and facial tracking. Advancements in depth camera technology has resulted in a noticeable increase in the integration of these technologies into portable platforms, suggesting significant future potential for pervasive in-clinic and field based health assessment solutions. This paper reviews the Intel RealSense technology's technical capabilities and discusses its application to clinical research and includes examples where the Intel RealSense camera range has been used for the measurement of health outcomes. This review supports the use of the technology to develop robust, objective movement and mobility-based endpoints to enable accurate tracking of the effects of treatment interventions in clinical trials.

Combined Vision and Wearable Sensors-based System for Movement Analysis in Rehabilitation

Background: Traditional rehabilitation sessions are often a slow, tedious, disempowering and non-motivational process, supported by clinical assessment tools, i.e. evaluation scales that are prone to subjective rating and imprecise interpretation of patient’s performance. Poor patient motivation and insufficient accuracy are thus critical factors that can be improved by new sensing/processing technologies.

Objectives: We aim to develop a portable and affordable system, suitable for home rehabilitation, which combines vision-based and wearable sensors. We introduce a novel approach for examining and characterizing the rehabilitation movements, using quantitative descriptors. We propose new Movement Performance Indicators (MPIs) that are extracted directly from sensor data and quantify the symmetry, velocity, and acceleration of the movement of different body/hand parts, and that can potentially be used by therapists for diagnosis and progress assessment.

Methods: First, a set of rehabilitation exercises is defined, with the supervision of neurologists and therapists for the specific case of Parkinson’s disease. It comprises full-body movements measured with a Kinect device and fine hand movements, acquired with a data glove. Then, the sensor data is used to compute 25 Movement Performance Indicators, to assist the diagnosis and progress monitoring (assessing the disease stage) in Parkinson’s disease. A kinematic hand model is developed for data verification and as an additional resource for extracting supplementary movement information.

Results: Our results show that the proposed Movement Performance Indicators are relevant for the Parkinson’s disease assessment. This is further confirmed by correlation of the proposed indicators with clinical tapping test and UPDRS clinical scale. Classification results showed the potential of these indicators to discriminate between the patients and controls, as well as between the stages that characterize the evolution of the disease.

Conclusions: The proposed sensor system, along with the developed approach for rehabilitation movement analysis have a significant potential to support and advance traditional rehabilitation therapy. The main impact of our work is two-fold: (i) the proposition of an approach for supporting the therapists during the diagnosis and monitoring evaluations by reducing subjectivity and imprecision, and (ii) offering the possibility of the system to be used at home for rehabilitation exercises in between sessions with doctors and therapists.

A Prototype Exercise-Empowerment Mobile Video Game for Children With Cancer, and Its Usability Assessment: Developing Digital Empowerment Interventions for Pediatric Diseases

BACKGROUND

Medical advances continue to improve morbidity and mortality of serious pediatric diseases, including cancer, driving research addressing diminished physical and psychological quality of life in children with these chronic conditions. Empowerment enhances resilience and positively influences health, disease, and therapy understanding. We describe the development and usability assessment of a prototype Empower Stars! mobile video game grounded in behavioral and exercise theories with the purpose of coupling physical exercise with empowerment over disease in children with cancer.

METHODS

Academic faculty, health-care providers, and community video game developers collaborated in this project. The iPadAir was selected as a delivery platform for its accelerometer and gyroscope features facilitating exercise design. Unity multiplatform technology provided animation and audiovisual features for immediate player feedback. Javascript, C#, Photoshop, Flash, and SketchUp were used for coding, creating graphical assets, Sprite sheets, and printing files, respectively. 3D-printed handles and case backing were used to adapt the iPad for physical exercise. Game usability, engagement, and enjoyment were assessed via a multilevel study of children undergoing cancer chemotherapy, their parents, and pediatric cancer health-care providers. Feedback crucial for ongoing game development was analyzed.

RESULTS

A prototype Empower Stars! mobile video game was developed for children 7-14 years old with cancer. Active, sedentary, educational, and empowerment-centered elements intermix for 20 min of exercise within a 30 min "one-day treatment" gameplay session involving superheroes, space exploration, metaphorical cancer challenges, life restoration on a barren planet, and innumerable star rewards. No player "dies." Usability assessment data analyses showed widespread enthusiasm for integrating exercise with empowerment over cancer and the game itself. Favorite elements included collecting star rewards and planet terraforming. Traveling in space and the Healthy Food Choice game were least liked. The need for improved gameplay instructions was expressed by all groups. The usability study provided essential feedback for converting the prototype into alpha version of Empower Stars!

CONCLUSION

Adapting exercise empowerment-promoting video game technology to mobile platforms facilitates usability and widespread dissemination for children with cancer. We discuss broader therapeutic applicability in diverse chronic pediatric diseases, including obesity, asthma, cystic fibrosis, diabetes, and juvenile idiopathic arthritis.

Effects of virtual rehabilitation versus conventional physical therapy on postural control, gait, and cognition of patients with Parkinson's disease: study protocol for a randomized controlled feasibility trial

Background

There is an association among postural instability, gait dysfunction, and cognitive impairment in subjects with Parkinson’s disease (PD). Difficulty in dividing attention, response inhibition, and visuospatial attention deficiencies may contribute to the impairment of motor performance during daily activities. There are strong evidences that physical therapy can prevent physical and cognitive decline in individuals with PD. Recently, the European Physiotherapy Guideline (EPG) was developed based on randomized clinical trials about the effectiveness of the physical therapy to improve the functional deficiencies of individuals with PD. The EPG did not include the use of promising new intervention as virtual reality in PD due the lack of studies about its safety, feasibility and effectiveness. Therefore, this study protocol had as objective to evaluate the feasibility, safety and effectiveness of a physical therapy program-based on the European Physiotherapy Guideline (EPG) compared to Kinect-based training on postural control, gait, cognition, and quality of life (QoL) of Individuals with PD.

Methods/design

A single-blind, parallel, randomized, controlled feasibility trial will be conducted with a sample of 32 individuals diagnosed with idiopathic PD. Participants will be allocated into control group (CG) and experimental group (EG). The intervention of the CG will be conventional physical therapy, and the intervention of the EG will be a supervised practice of five Kinect games. Both groups will perform 14 sessions of 1 h each one, twice a week over 7 weeks. Process outcomes will be safety, feasibility, adherence, and acceptability. Safety will be assessed by the proportion of participants who experienced intervention-related adverse events or any serious adverse event during the study period. Feasibility will be assessed through the scores of the games recorded in all training sessions. Adherence will be assessed through the participant’s attendance. Acceptability will be the motivation of the participants regarding the interventions. Clinical outcomes will be (1) postural control, (2) cognitive function, (3) balance, (4) gait, and (5) QoL. Individuals will be assessed pre- and post-interventions and after 30 days by a blinded evaluator.

Discussion

This protocol will clarify if an intervention based on Kinect games will be feasible, safe, and acceptable for individuals with PD compared to conventional physical therapy. We will verify whether the proposed interventions can improve clinical outcomes as postural control, gait, cognition, and QoL of individuals with PD. Our hypothesis is that both Kinect games and conventional physical therapy will be feasible, safe, and acceptable for individuals with PD and will promote positive clinical effects. The results of this feasibility study will be used to design a future definitive clinical trial.

Trial registration

Unique identification number in WHO Trial Registration: U1111-1171-0371. Brazilian Clinical Trial Registration Number RBR-27kqv5, registration date: February, 2016.

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0210-3) contains supplementary material, which is available to authorized users.

The Kinect Project: Group motion-based gaming for people living with dementia

Engaging in enjoyable activities is an essential part of well-being, but people with dementia can find participation increasingly difficult. Motion-based technologies can provide meaningful engagement in a wide range of activities, but for people with dementia to take advantage of these devices requires a good understanding of how best to select and present these activities to this population. The objective of this study was to explore the use of motion-based technology (Xbox Kinect) as a group activity for people with dementia who attend adult day programmes. This qualitative study took place in an adult day programme for older adults with age-related challenges. Participants (n = 23) were observed while playing a digital bowling game presented on Xbox Kinect one hour per week for a period of 20 weeks, to capture naturalistic data. Field notes generated through observations were transcribed and analysed to identify emerging themes. The findings revealed three predominant themes which illustrate the potential of motion-based technology as a group activity for people with dementia who attend adult day programmes: (a) the importance of having a trained trainer, (b) learning versus mastery and (c) playing ‘independently together’. People with dementia can learn to play games presented on motion-based technology and enjoy doing so. Furthermore, using the technology in a group setting fostered an encouraging and supportive environment which further contributed to the leisure experience. However, to be used most effectively, staff must be trained to set-up and interact with the technology, as well as introduce, teach and support people with dementia to use it.

Feasibility, safety, acceptability, and functional outcomes of playing Nintendo Wii Fit Plus™ for frail elderly: study protocol for a feasibility trial

Background

Frailty can be defined as a medical syndrome with multiple causes and contributors, characterized by diminished strength and endurance and reduced physiological function that increases the vulnerability to develop functional dependency and/or death. Studies have shown that the most commonly studied exercise protocol for frail older adults is the multimodal training. Interactive video games (IVGs) involve tasks in virtual environments that combine physical and cognitive demands in an attractive and challenging way. The aim of this study will be to evaluate the feasibility, safety, acceptability, and functional outcomes of playing Nintendo Wii Fit Plus^TM (NWFP) for frail older adults.

Methods/design

The study is a randomized controlled, parallel group, feasibility trial. Participants will be randomly assigned to the experimental group (EG) and control group (CG). The EG will participate in 14 training sessions, each lasting 50 min, twice a week. In each training session, the participants will play five games, with three attempts at each game. The first attempt will be performed with the assistance of a physical therapist to correct the movements and posture of the patients and subsequent attempts will be performed independently. Scores achieved in the games will be recorded. The participants will be evaluated by a blinded physical therapist at three moments: before and after intervention and 30 days after the end of the intervention (follow-up). We will assess the feasibility, acceptability, safety, and clinical outcomes (postural control, gait, cognition, quality of life, mood, and fear of falling).

Discussion

Due to the deficiencies in multiple systems, studies have shown that multimodal interventions including motor-cognitive stimulation can improve the mobility of frail elderly adults. IVGs, among them the NWFP, are considered as a multimodal motor-cognitive intervention that can potentially improve motor and cognitive functions in the frail elderly. However, there is still no evidence in the literature that proves the feasibility, safety, acceptability, and functional outcomes of this intervention in frail elderly individuals.

Trial registration

Brazilian Registry of Clinical Trials (RBR-823rst). World Health Organization Trial Registration Data Set (Additional file 1).

Electronic supplementary material

The online version of this article (10.1186/s40814-017-0184-1) contains supplementary material, which is available to authorized users.

Touch-free reaching task for Parkinson's disease patients: A motion sensing approach

The use of motion tracking devices in healthcare is under investigation. Although many motion tracking applications have been proposed to monitor the progress of rehabilitation, using such technology to quantify the progression or improvement of therapies for movement disorders is still scarce. In this study, we introduce a touch-free reaching task which uses a motion sensing device. Our motion tracking system combines a motion tracking device and visual feedback to implement a movement task for the evaluation of the state of motor functions impairment symptoms in Parkinson's disease and other movement disorders.

New Approaches to Exciting Exergame-Experiences for People with Motor Function Impairments

The work presented here suggests new ways to tackle exergames for physical rehabilitation and to improve the players’ immersion and involvement. The primary (but not exclusive) purpose is to increase the motivation of children and adolescents with severe physical impairments, for doing their required exercises while playing. The proposed gaming environment is based on the Kinect sensor and the Blender Game Engine. A middleware has been implemented that efficiently transmits the data from the sensor to the game. Inside the game, different newly proposed mechanisms have been developed to distinguish pure exercise-gestures from other movements used to control the game (e.g., opening a menu). The main contribution is the amplification of weak movements, which allows the physically impaired to have similar gaming experiences as the average population. To test the feasibility of the proposed methods, four mini-games were implemented and tested by a group of 11 volunteers with different disabilities, most of them bound to a wheelchair. Their performance has also been compared to that of a healthy control group. Results are generally positive and motivating, although there is much to do to improve the functionalities. There is a major demand for applications that help to include disabled people in society and to improve their life conditions. This work will contribute towards providing them with more fun during exercise.

The Use of Motion-Based Technology for People Living With Dementia or Mild Cognitive Impairment: A Literature Review

Background

The number of people living with dementia and mild cognitive impairment (MCI) is increasing substantially. Although there are many research efforts directed toward the prevention and treatment of dementia and MCI, it is also important to learn more about supporting people to live well with dementia or MCI through cognitive, physical, and leisure means. While past research suggests that technology can be used to support positive aging for people with dementia or MCI, the use of motion-based technology has not been thoroughly explored with this population.

Objective

The aim of this study was to identify and synthesize the current literature involving the use of motion-based technology for people living with dementia or MCI by identifying themes while noting areas requiring further research.

Methods

A systematic review of studies involving the use of motion-based technology for human participants living with dementia or MCI was conducted.

Results

A total of 31 articles met the inclusion criteria. Five questions are addressed concerning (1) context of use; (2) population included (ie, dementia, MCI, or both); (3) hardware and software selection; (4) use of motion-based technology in a group or individual setting; and (5) details about the introduction, teaching, and support methods applied when using the motion-based technology with people living with dementia or MCI.

Conclusions

The findings of this review confirm the potential of motion-based technology to improve the lives of people living with dementia or MCI. The use of this technology also spans across several contexts including cognitive, physical, and leisure; all of which support multidimensional well-being. The literature provides evidence that people living with dementia or MCI can learn how to use this technology and that they enjoy doing so. However, there is a lack of information provided in the literature regarding the introduction, training, and support methods applied when using this form of technology with this population. Future research should address the appropriate introduction, teaching, and support required for people living with dementia or MCI to use the motion-based technology. In addition, it is recommended that the diverse needs of these specific end-users be considered in the design and development of this technology.

MirrARbilitation: A clinically-related gesture recognition interactive tool for an AR rehabilitation system

BACKGROUND AND OBJECTIVE

Interactive systems for rehabilitation have been widely investigated for motivational purposes. However, more attention should be given to the manner in which user movements are recognized and categorized. This paper aims to evaluate the efficacy of using a clinically-related gesture recognition tool, based on the international biomechanical standards (ISB) for the reporting of human joint motion, for the development of an interactive augmented reality (AR) rehabilitation system -mirrARbilitation.

METHODS

This work presents an AR rehabilitation system based on ISB standards, which enables the system to interact and to be configured according to therapeutic needs. The Kinect(TM) skeleton tracking technology was exploited and a new movement recognition method was developed to recognize and classify biomechanical movements. Further, our mirrARbilitation system provides exercise instructions while simultaneously motivating the patient. The system was evaluated on a cohort of 33 patients, physiotherapists, and software developers when performing shoulder abduction therapy exercises. Tests were performed in three moments: (i) users performed the exercise until they feel tired without the help of the system, (ii) the same however using the mirrARbilitation for motivation and guidance, and (iii) users performed the exercise again without the system. Users performing the movement without the help of the system worked as baseline reference.

RESULTS

We demonstrated that the percentage of correct exercises, measured by the movement analysis method we developed, improved from 69.02% to 93.73% when users interacted with the mirrARbilitation. The number of exercise repetitions also improved from 34.06 to 66.09 signifying that our system increased motivation of the users. The system also prevented the users from performing the exercises in a completely wrong manner. Finally, with the help of our system the users' worst result was performing 73.68% of the rehabilitation movements correctly. Besides the engagement, these results suggest that the use of biomechanical standards to recognize movements is valuable in guiding users during rehabilitation exercises.

CONCLUSION

The proposed system proved to be efficient by improving the user engagement and exercise performance outcomes. The results also suggest that the use of biomechanical standards to recognize movements is valuable in guiding users during rehabilitation exercises.

Influence of the Perspectives on the Movement of One-Leg Lifting in an Interactive-Visual Virtual Environment: A Pilot Study

Background

Numerous studies have confirmed the feasibility of active video games for clinical rehabilitation. To maximize training effectiveness, a personal program is necessary; however, little evidence is available to guide individualized game design for rehabilitation. This study assessed the perspectives and kinematic and temporal parameters of a participant’s postural control in an interactive-visual virtual environment.

Methods

Twenty-four healthy participants performed one-leg standing by leg lifting when a posture frame appeared either in a first- or third-person perspective of a virtual environment. A foot force plate was used to detect the displacement of the center of pressure. A three-way mixed factor design was applied, where the perspective was the between-participant factor, and the leg-lifting times (0.7 and 2.7 seconds) and leg-lifting angles (30°and 90°) were the within-participant factors. The reaction time, accuracy of the movement, and ability to shift weight were the dependent variables.

Results

Regarding the reaction time and accuracy of the movement, there were no significant main effects of the perspective, leg-lifting time, or angle. For the ability to shift weight, however, both the perspective and time exerted significant main effects, F(1,22) = 6.429 and F(1,22) = 13.978, respectively.

Conclusions

Participants could shift their weight more effectively in the third-person perspective of the virtual environment. The results can serve as a reference for future designs of interactive-visual virtual environment as applied to rehabilitation.

A benefit-cost framework of motivation for a specific activity

How can an individual be motivated to perform a target exercise or activity? This question arises in training, therapeutic, and education settings alike, yet despite-or even because of-the large range of extant motivation theories, finding a clear answer to this question can be challenging. Here we propose an application-friendly framework of motivation for a specific activity or exercise that incorporates core concepts from several well-regarded psychological and economic theories of motivation. The key assumption of this framework is that motivation for performing a given activity is determined by the expected benefits and the expected costs of (performance of) the activity. Benefits comprise positive feelings, gains, and rewards experienced during performance of the activity (intrinsic benefits) or achieved through the activity (extrinsic benefits). Costs entail effort requirements, time demands, and other expenditure (intrinsic costs) as well as unwanted associated outcomes and missing out on alternative activities (extrinsic costs). The expected benefits and costs of a given exercise are subjective and state dependent. We discuss convergence of the proposed framework with a selection of extant motivation theories and briefly outline neurobiological correlates of its main components and assumptions. One particular strength of our framework is that it allows to specify five pathways to increasing motivation for a target exercise, which we illustrate and discuss with reference to previous empirical data.

KINECT-BASED SKELETON-MATCHING FEEDBACK FOR MOTOR REHABILITATION: TRANSIENT PERFORMANCE EFFECT OF SHOULDER TRAINING

For motor learning tasks, different feedback methods to the user may impact the efficiency of motor training. Microsoft Kinect has shown great potential as an assistive device for home-based exercise training. This study introduces a Kinect-based skeleton-matching feedback system and compares its training outcomes with those of traditional mirror feedback in order to explore its applicability for use in home-based motor training. Forty healthy adults were randomly divided into an experimental group and a control group, and were instructed to perform a set of continuous shoulder motions using Kinect-based skeleton-matching feedback and traditional mirror feedback respectively. Fisher’s z-transformed Pearson’s correlation coefficient ([Formula: see text]) and root-mean-square error (RMSE) were used to evaluate angular differences in shoulder movements between the subject’s actual motion and a reference motion for each group. Compared to the results under mirror feedback, r values with skeleton-matching feedback were significantly improved for symmetric abduction (SA), asymmetric abduction (ASA), and symmetric flexion/extension (SFE) ([Formula: see text]), and RMSE values were significantly decreased for symmetric flexion/extension (SFE) ([Formula: see text]). Therefore, the Kinect-based skeleton-matching feedback system boasts greater training efficiency for shoulder motor learning and has great potential as an assistive device for home-based rehabilitation exercise training.

Exercise and rehabilitation delivered through exergames in older adults: An integrative review of technologies, safety and efficacy

BACKGROUND

There has been a rapid increase in research on the use of virtual reality (VR) and gaming technology as a complementary tool in exercise and rehabilitation in the elderly population. Although a few recent studies have evaluated their efficacy, there is currently no in-depth description and discussion of different game technologies, physical functions targeted, and safety issues related to older adults playing exergames.

OBJECTIVES

This integrative review provides an overview of the technologies and games used, progression, safety measurements and associated adverse events, adherence to exergaming, outcome measures used, and their effect on physical function.

METHODS

We undertook systematic searches of SCOPUS and PubMed databases. Key search terms included "game", "exercise", and "aged", and were adapted to each database. To be included, studies had to involve older adults aged 65 years or above, have a pre-post training or intervention design, include ICT-implemented games with weight-bearing exercises, and have outcome measures that included physical activity variables and/or clinical tests of physical function.

RESULTS

Sixty studies fulfilled the inclusion criteria. The studies had a broad range of aims and intervention designs and mostly focused on community-dwelling healthy older adults. The majority of the studies used commercially available gaming technologies that targeted a number of different physical functions. Most studies reported that they had used some form of safety measure during intervention. None of the studies reported serious adverse events. However, only 21 studies (35%) reported on whether adverse events occurred. Twenty-four studies reported on adherence, but only seven studies (12%) compared adherence to exergaming with other forms of exercise. Clinical measures of balance were the most frequently used outcome measures. PEDro scores indicated that most studies had several methodological problems, with only 4 studies fulfilling 6 or more criteria out of 10. Several studies found positive effects of exergaming on balance and gait, while none reported negative effects.

CONCLUSION

Exergames show promise as an intervention to improve physical function in older adults, with few reported adverse events. As there is large variability between studies in terms of intervention protocols and outcome measures, as well as several methodological limitations, recommendations for both practice and further research are provided in order to successfully establish exergames as an exercise and rehabilitation tool for older adults.