Clinical feasibility of interactive motion-controlled games for stroke rehabilitation

Development of a Motion-Based Video Game for Postural Training: A Feasibility Study on Older Adults With Adult Degenerative Scoliosis

Forward sagittal alignment affects physical performance, is associated with pain and impacts the health-related quality of life of the elderly. Interventions that help seniors to improve sagittal balance are needed to inhibit the progression of pain and disability. A motion-sensing video game (active game) is developed in this study to monitor sitting and standing postures in real-time and facilitate the postural learning process by using optical sensors to measure body movement and a video game to provide visual feedback. Ten female subjects (mean age: 60.0 ± 5.2 years old; mean BMI: 21.4 ± 1.9) with adult degenerative scoliosis (mean major Cobb's angle: 38.1° ± 22.7°) participate in a 6-week postural training programme with three one-hour postural training sessions a week. Eleven body alignment measurements of their perceived "ideal" sitting and standing postures are obtained before and after each training session to evaluate the effectiveness of postural learning with the game. The participants learn to sit and stand with increased sagittal alignment with a raised chest and more retracted head position. The forward shift of their head and upper body is significantly reduced after each training session. Although this immediate effect only partially sustained after the 6-week program, the participants learned to adjust their shoulder and pelvis level for a better lateral alignment in standing. The proposed postural training system, which is presented as a gameplay with real-time visual feedback, can effectively help players to improve their postures. This pilot feasibility study explores the development and initial assessment of a motion-based video game designed for postural training in older adults with adult degenerative scoliosis, and demonstrates the usability and benefits of active gameplay in motor training.

Exploring the Efficacy of Physiotherapy in Guillain-Barré Syndrome Through Virtual Reality-Based Rehabilitation: A Case Report

Guillain-Barré syndrome (GBS) refers to a spectrum of acute immune-mediated polyradiculoneuropathies, among which is acute motor axonal neuropathy (AMAN), which is typified by predominant motor involvement and axonal degeneration. This case study describes the presentation, diagnosis, and physiotherapy management using virtual reality-based technology in a 29-year-old male patient with AMAN. Nerve conduction velocity testing was used to diagnose motor axonal neuropathy in the patient, who had weakness subsequent to gastrointestinal symptoms. Intravenous immunoglobulin therapy was started, and a physiotherapy protocol was planned for eight weeks according to the patient's functional status. Physiotherapy plays an important role in the rehabilitation of patients with GBS, addressing the specific motor deficits and promoting recovery. The aim was to improve muscle strength, mobility, and functional independence through progressive exercises targeting specific motor deficits. Virtual reality-based training was also part of this rehabilitation process as an adjunct to conventional rehabilitation to improve dynamic balance and function of the upper and lower limbs, which showed significant improvement in the outcome measures.

EFFECT OF RESISTANCE TRAINING THROUGH IN-PERSON AND TELECONFERENCING SESSIONS IN REHABILITATION OF ACUTE STROKE PATIENTS

Objective

To determine whether application of a strength training regimen yields measurable results on stroke survivors and compare different methods for the proposed intervention.

Design Patients and Methods

Ninety stroke patients were recruited from the neurological clinic of a local third-level clinic. Sixty patients participated in a strength training regimen with trainings taking place 3 times a week for 12 weeks with the use of resistance bands. Thirty of these patients were given face-to-face sessions and 30 patients were given trainings through an on-line platform. The last 30 patients who comprised the control group only followed usual care after the stroke.

Results

The applied strength regimen had a statistically significant effect on Visual Analog Scale scores of stroke patients who received it (p = 0.009), as well as in the teleconferencing group (p = 0.004). The measured arteriovenous oxygen difference was elevated for stroke patients who received the intervention as a whole (p = 0.007). Patients who were trained in person and the ones who were trained via teleconferencing yielded similar results as evaluated through the VAS index.

Discussion and Conclusion

Administration of strength training 3 times weekly for 12 weeks to stroke patients yielded measurable results in terms of general function and quality of life.

Sensor-Controlled Digital Game for Heart Failure Self-management: Protocol for a Randomized Controlled Trial

BACKGROUND

Heart failure (HF) is the leading cause of hospitalization among older adults in the United States. There are substantial racial and geographic disparities in HF outcomes, with patients living in southern US states having a mortality rate 69% higher than the national average. Self-management behaviors, particularly daily weight monitoring and physical activity, are extremely important in improving HF outcomes; however, patients typically have particularly low adherence to these behaviors. With the rise of digital technologies to improve health outcomes and motivate health behaviors, sensor-controlled digital games (SCDGs) have become a promising approach. SCDGs, which leverage sensor-connected technologies, offer the benefits of being portable and scalable and allowing for continuous observation and motivation of health behaviors in their real-world contexts. They are also becoming increasingly popular among older adults and offer an immersive and accessible way to measure self-management behaviors and improve adherence. No SCDGs have been designed for older adults or evaluated to test their outcomes.

OBJECTIVE

This randomized clinical trial aims to assess the efficacy of a SCDG in integrating the behavioral data of participants with HF from weight scale and activity tracker sensors to activate game progress, rewards, and feedback and, ultimately, to improve adherence to important self-management behaviors.

METHODS

A total of 200 participants with HF, aged ≥45 years, will be recruited and randomized into 2 groups: the SCDG playing group (intervention group) and sensor-only group (control group). Both groups will receive a weight scale, physical activity tracker, and accompanying app, whereas only the intervention group will play the SCDG. This design, thereby, assesses the contributions of the game. All participants will complete a baseline survey as well as posttests at 6 and 12 weeks to assess the immediate effect of the intervention. They will also complete a third posttest at 24 weeks to assess the maintenance of behavioral changes. Efficacy and benefits will be assessed by measuring improvements in HF-related proximal outcomes (self-management behaviors of daily weight monitoring and physical activity) and distal outcomes (HF hospitalization, quality of life, and functional status) between baseline and weeks 6, 12, and 24. The primary outcome measured will be days with weight monitoring, for which this design provides at least 80% power to detect differences between the 2 groups.

RESULTS

Recruitment began in the fall of 2022, and the first patient was enrolled in the study on November 7, 2022. Recruitment of the last participant is expected in quarter 1 of 2025. Publication of complete results and data from this study is expected in 2026.

CONCLUSIONS

This project will generate insight and guidance for scalable and easy-to-use digital gaming solutions to motivate persistent adherence to HF self-management behaviors and improve health outcomes among individuals with HF.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05056129; https://clinicaltrials.gov/ct2/show/NCT05056129.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/45801.

Transcranial direct current stimulation with virtual reality versus virtual reality alone for upper extremity rehabilitation in stroke: A meta-analysis

Background

Stroke is one of the most prevalent diseases. Motor impairment in patients with stroke frequently affects the upper extremities. Several randomized clinical trials (RCTs) have tried to prove whether or not the combination of transcranial direct current stimulation (tDCS) with virtual reality (VR) is superior to VR alone for upper extremity rehabilitation.

Methods

We searched Embase, MEDLINE, the Cochrane Library database, and Clinicaltrials.gov for relevant RCTs published before June 10, 2022. The results were analyzed by using standard mean differences (SMD) and 95% confidence intervals (95% CI).

Results

We pooled 120 patients from 4 RCTs. There were no significant improvements in the Fugl-Meyer Upper Extremity scale (SMD = 0.51; 95% CI, -0.04 to 1.06), the Box and Block Test (SMD = 0.42; 95% CI, -0.02 to 0.86), and the Modified Ashworth Scale after the combined treatment of tDCS and VR. But tDCS combined with VR could enhance the Barthel Index scores in patients with stroke compared to VR alone (SMD = 0.49; 95% CI, 0.04 to 0.94).

Conclusions

The combination of tDCS and VR can improve the quality of daily living in patients with stroke. No more satisfactory efficacy has been demonstrated in terms of upper extremity function. However, we observe a distinct trend toward significance in some outcomes.

A novel home-based rehabilitative knee brace system is a viable option for postoperative rehabilitation after anterior cruciate ligament reconstruction: a report of 15 cases

Purpose

To investigate the functional outcomes for patients who used a novel home-based rehabilitative system during the postoperative period after anterior cruciate ligament (ACL) reconstructions.

Methods

Patients undergoing ACL reconstruction surgeries were prospectively enrolled. A home-based rehabilitation system, which is composed of a knee brace with a motion tracker, a mobile app, and a web portal, was applied. Patients could complete the rehabilitation exercise through the audio guidance and the real-time tracking system which displayed the achieved motions on the user interface of the app. Feedbacks from the patients, including the International Knee Documentation Committee (IKDC) scores, were collected and uploaded to the web portal. Each patient would meet a specialized physical therapist face-to-face once a month. At postoperative 6 months, every patient received a GNRB arthrometer examination and a Cybex isokinetic dynamometer examination.

Results

A total of 15 patients (10 males and 5 females) were enrolled and followed for at least 6 months. The mean time of return to full knee extension was 1.5 months.

The mean difference in laxity measured by GNRB arthrometer at 134 N significantly improved at postoperative 6 months (1.8 ± 1.6 mm) compared to that measured preoperatively (3.4 ± 1.9 mm) (p = 0.024). The peak torques of flexor and extensor muscles measured by Cybex isokinetic dynamometer remained unchanged at postoperative 6 months (p = 0.733 and 0.394, respectively). The patients’ IKDC score became smaller at postoperative 1 month (p = 0.011) and significantly improved at postoperative 6 months (p = 0.002).

Conclusion

Using a home-based rehabilitative knee brace system after ACL reconstruction is a viable option as patients maintained their knee muscle strengths maintained their muscle strength and achieve similar or better knee range of motion six months postoperatively.

Graph Convolutional Networks for Assessment of Physical Rehabilitation Exercises

Health professionals often prescribe patients to perform specific exercises for rehabilitation of several diseases (e.g., stroke, Parkinson, backpain). When patients perform those exercises in the absence of an expert (e.g., physicians/therapists), they cannot assess the correctness of the performance. Automatic assessment of physical rehabilitation exercises aims to assign a quality score given an RGBD video of the body movement as input. Recent deep learning approaches address this problem by extracting CNN features from co-ordinate grids of skeleton data (body-joints) obtained from videos. However, they could not extract rich spatio-temporal features from variable-length inputs. To address this issue, we investigate Graph Convolutional Networks (GCNs) for this task. We adapt spatio-temporal GCN to predict continuous scores(assessment) instead of discrete class labels. Our model can process variable-length inputs so that users can perform any number of repetitions of the prescribed exercise. Moreover, our novel design also provides self-attention of body-joints, indicating their role in predicting assessment scores. It guides the user to achieve a better score in future trials by matching the same attention weights of expert users. Our model successfully outperforms existing exercise assessment methods on KIMORE and UI-PRMD datasets.

Serious Game Design and Clinical Improvement in Physical Rehabilitation: Systematic Review

Background

Serious video games have now been used and assessed in clinical protocols, with several studies reporting patient improvement and engagement with this type of therapy. Even though some literature reviews have approached this topic from a game perspective and presented a broad overview of the types of video games that have been used in this context, there is still a need to better understand how different game characteristics and development strategies might impact and relate to clinical outcomes.

Objective

This review assessed the relationship between the characteristics of serious games (SGs) and their relationship with the clinical outcomes of studies that use this type of therapy in motor impairment rehabilitation of patients with stroke, multiple sclerosis, or cerebral palsy. The purpose was to take a closer look at video game design features described in the literature (game genre [GG], game nature [GN], and game development strategy [GDS]) and assess how they may contribute toward improving health outcomes. Additionally, this review attempted to bring together medical and game development perspectives to facilitate communication between clinicians and game developers, therefore easing the process of choosing the video games to be used for physical rehabilitation.

Methods

We analyzed the main features of SG design to obtain significant clinical outcomes when applied to physical rehabilitation of patients recovering from motor impairments resulting from stroke, multiple sclerosis, and cerebral palsy. We implemented a PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) database-adjusted electronic search strategy for the PubMed, IEEE Xplore, and Cochrane databases.

Results

We screened 623 related papers from 2010-2021 and identified 12 that presented results compatible with our inclusion criteria. A total of 512 participants with stroke (8 studies, 417 participants), cerebral palsy (1 study, 8 participants), and multiple sclerosis (2 studies, 46 participants) were included; 1 study targeting the elderly (41 participants) was also included. All studies assessed motor, sensory, and functional functions, while some also measured general health outcomes. Interventions with games were used for upper-limb motor rehabilitation. Of the 12 studies, 8 presented significant improvements in at least one clinical measurement, of which 6 presented games from the casual GG, 1 combined the casual, simulation, and exergaming GGs, and 2 combined the sports and simulation GGs.

Conclusions

Of the possible combinations of game design features (GG, GN, and GDS) described, custom-made casual games that resort to the first-person perspective, do not feature a visible player character, are played in single-player mode, and use nonimmersive virtual reality attain the best results in terms of positive clinical outcomes. In addition, the use of custom-made games versus commercial off-the-shelf games tends to give better clinical results, although the latter are perceived as more motivating and engaging.

Serious games as rehabilitation tools in neurological conditions: A comprehensive review

BACKGROUND

The use of serious games (SG) in rehabilitation has been on the rise in recent years and they are used as either a main interventional tool, or as an adjunct alongside conventional therapies. This is largely due to its virtue of being an electronic platform hence possessing game characteristics that facilitates patient progress.

OBJECTIVE

The present study aimed to provide a comprehensive review of the impact of SG on neurorehabilitation therapies as well as patients' perspectives on rehabilitation.

METHODS

The literature search was conducted in PubMed and Cochrane databases. The study was conducted in four different phases, consisting of the generation of MeSH terms and keywords, screening of articles, and data analysis based on the study characteristics.

RESULTS

This review included 47 studies that explored the use of custom designed experimental serious games (ESG) or commercially designed serious games (CSG) for rehabilitation in a few neurological conditions. The majority of CSG used Nintendo Wii as an adjunct to conventional therapies. Significant improvement in the primary outcomes such as motor functioning, balance, executive and cognitive functions were reported in 35 studies. 17 studies also indicated patient perspectives on rehabilitation. There was no difference between the overall impact of either CSG or ESG.

CONCLUSION

Evidently, SG are efficient exergame tools. However, future studies should explore patient perspectives that could help to design evidence-based games for rehabilitation purposes.

The impact of visuospatial perception on distance judgment and depth perception in an Augmented Reality environment in patients after stroke: an exploratory study

BACKGROUND

Augmented Reality (AR)-based interventions are applied in neurorehabilitation with increasing frequency. Depth perception is required for the intended interaction within AR environments. Until now, however, it is unclear whether patients after stroke with impaired visuospatial perception (VSP) are able to perceive depth in the AR environment.

METHODS

Different aspects of VSP (stereovision and spatial localization/visuoconstruction) were assessed in 20 patients after stroke (mean age: 64 ± 14 years) and 20 healthy subjects (HS, mean age: 28 ± 8 years) using clinical tests. The group of HS was recruited to assess the validity of the developed AR tasks in testing stereovision. To measure perception of holographic objects, three distance judgment tasks and one three-dimensionality task were designed. The effect of impaired stereovision on performance in each AR task was analyzed. AR task performance was modeled by aspects of VSP using separate regression analyses for HS and for patients.

RESULTS

In HS, stereovision had a significant effect on the performance in all AR distance judgment tasks (p = 0.021, p = 0.002, p = 0.046) and in the three-dimensionality task (p = 0.003). Individual quality of stereovision significantly predicted the accuracy in each distance judgment task and was highly related to the ability to perceive holograms as three-dimensional (p = 0.001). In stroke-survivors, impaired stereovision had a specific deterioration effect on only one distance judgment task (p = 0.042), whereas the three-dimensionality task was unaffected (p = 0.317). Regression analyses confirmed a lacking impact of patients' quality of stereovision on AR task performance, while spatial localization/visuoconstruction significantly prognosticated the accuracy in distance estimation of geometric objects in two AR tasks.

CONCLUSION

Impairments in VSP reduce the ability to estimate distance and to perceive three-dimensionality in an AR environment. While stereovision is key for task performance in HS, spatial localization/visuoconstruction is predominant in patients. Since impairments in VSP are present after stroke, these findings might be crucial when AR is applied for neurorehabilitative treatment. In order to maximize the therapy outcome, the design of AR games should be adapted to patients' impaired VSP.  Trial registration: The trial was not registered, as it was an observational study.

Identifying key elements to assess patient's acceptability of neurorehabilitation in stroke survivors - a Delphi method

PURPOSE

Assessing patient acceptability of treatment is a clinical concern. No guidance exists to determine the best way to measure acceptability in stroke neurorehabilitation. This study identifies key elements to measure patient's acceptance of stroke neurorehabilitation by establishing expert consensus.

MATERIALS AND METHODS

A four-phase Delphi method with a three-round electronic-based survey was conducted. Experts were considered as stroke survivors or their caregivers and professionals in stroke neurorehabilitation. A twenty-five-item list was sourced from a literature review and discussion with a consumer panel (n = 22). In Round-1 (n = 118) and Round-2 (n = 80), experts ranked the items on a five-point scale. Consensus levels were validated by a Validation group in Round-3 (n = 50). Validity of the results was considered if consensus reached ≥70%, a non-bimodal pattern of response central tendency, SD in Round-2 was lower than that in Round-1, and the agreement scores of responses were similar between all rounds.

RESULTS

In Round-1&2 and Round-3, 77.5% (n = 62) and 74.0% (n = 37) respectively, of the respondents were professionals, 20.0% (n = 16, n = 10 respectively) were either stroke survivors or caregivers, and 2.57% (n = 2) and 6.0% (n = 3) respectively were professionals who themselves were stroke survivors or caregivers. The key elements which met all priori criteria are: Goal setting, Measurable progress, Functional improvement, Challenging, Motivation, Interactive, Communications with health professionals, Knowledge of treatment, and No risks.

CONCLUSIONS

Patient's acceptance is crucial to developing the appropriate neurorehabilitation interventions. Future clinical trials should consider these items when measuring patient's acceptance of stroke neurorehabilitation interventions during the development and evaluation phases.Implications for rehabilitationAssessing patient acceptability of treatment is a clinical concern in stroke neurorehabilitation.This study has identified nine key elements to assess patient acceptability of stroke neurorehabilitation. These key elements are: Goal setting, Measurable progress, Functional improvement, Challenging, Motivation, Interactive, Communications with health professionals, Knowledge of treatment, and No risks.Professionals should consider these elements when measuring patient's acceptance of an intervention during the development, piloting, evaluation, and implementation phases.These findings provide a framework in designing neurorehabilitation programs and clinical trials on acceptance of and adherence to treatment in stroke survivors.

Serious Gaming Technology in Upper Extremity Rehabilitation: Scoping Review

Background

Serious gaming has increasingly gained attention as a potential new component in clinical practice. Specifically, its use in the rehabilitation of motor dysfunctions has been intensively researched during the past three decades.

Objective

The aim of this scoping review was to evaluate the current role of serious games in upper extremity rehabilitation, and to identify common methods and practice as well as technology patterns. This objective was approached via the exploration of published research efforts over time.

Methods

The literature search, using the PubMed and Scopus databases, included articles published from 1999 to 2019. The eligibility criteria were (i) any form of game-based arm rehabilitation; (ii) published in a peer-reviewed journal or conference; (iii) introduce a game in an electronic format; (iv) published in English; and (v) not a review, meta-analysis, or conference abstract. The search strategy identified 169 relevant articles.

Results

The results indicated an increasing research trend in the domain of serious gaming deployment in upper extremity rehabilitation. Furthermore, differences regarding the number of publications and the game approach were noted between studies that used commercial devices in their rehabilitation systems and those that proposed a custom-made robotic arm, glove, or other devices for the connection and interaction with the game platform. A particularly relevant observation concerns the evaluation of the introduced systems. Although one-third of the studies evaluated their implementations with patients, in most cases, there is the need for a larger number of participants and better testing of the rehabilitation scheme efficiency over time. Most of the studies that included some form of assessment for the introduced rehabilitation game mentioned user experience as one of the factors considered for evaluation of the system. Besides user experience assessment, the most common evaluation method involving patients was the use of standard medical tests. Finally, a few studies attempted to extract game features to introduce quantitative measurements for the evaluation of patient improvement.

Conclusions

This paper presents an overview of a significant research topic and highlights the current state of the field. Despite extensive attempts for the development of gamified rehabilitation systems, there is no definite answer as to whether a serious game is a favorable means for upper extremity functionality improvement; however, this certainly constitutes a supplementary means for motivation. The development of a unified performance quantification framework and more extensive experiments could generate richer evidence and contribute toward this direction.

Vieten M. The Gaitprint: Identifying Individuals by Their Running Style

Recognizing the characteristics of a well-developed running style is a central issue in athletic sub-disciplines. The development of portable micro-electro-mechanical-system (MEMS) sensors within the last decades has made it possible to accurately quantify movements. This paper introduces an analysis method, based on limit-cycle attractors, to identify subjects by their specific running style. The movement data of 30 athletes were collected over 20 min. in three running sessions to create an individual gaitprint. A recognition algorithm was applied to identify each single individual as compared to other participants. The analyses resulted in a detection rate of 99% with a false identification probability of 0.28%, which demonstrates a very sensitive method for the recognition of athletes based solely on their running style. Further, it can be seen that these differentiations can be described as individual modifications of a general running pattern inherent in all participants. These findings open new perspectives for the assessment of running style, motion in general, and a person's identification, in, for example, the growing e-sports movement.

Exploring serious games for stroke rehabilitation: a scoping review

Aims and Objectives: Stroke is the main cause of long-term disability and happens mostly in the older population. Stroke affected patients experience either of the cognitive, visual or motor losses and recovery requires time and patience as they have to do physical exercises every day and at times repetitively. There are various types of stroke rehabilitation exercises focussing on technological solutions that include therapies performed using games. Motion-based games are popular in encouraging participants to perform repetitive tasks without being getting bored. Therefore, in this study, we have explored studies that included the use of games for stroke rehabilitation to understand the design principles and characteristics of the games used for these purposes. Method: A number of medical respositories were searched for relevant articles in a window of 2008-2018. 18 studies were chosen for the scoping review depending on the inclusion criteria, and design principles used in these studies are analysed and evaluated. Results and Conclusion: We present main findings from our review concerning the attributes of existing games for stroke rehabilitation such as meaningful play, handling of failures, emphasising challenge, and the value of feedback. We conclude with a list of design recommendations that future serious game developers can consider while designing interfaces for stroke patients.Implications for RehabilitationThis review exhibits that the usage of gaming technologies is a very effective interactive mechanism for stroke based rehabilitation.Further our review also shows that serious games provide an avenue and opportunity for customized and highly contextualized gameplayOur review also suggests that effective features to incorporate into serious games for rehabilitation includes; facilitating challenge and recovery from errors.

Developing ActivABLES for community-dwelling stroke survivors using the Medical Research Council framework for complex interventions

BACKGROUND

Novel technical solutions are called for to promote home-based exercise among community-dwelling stroke survivors supported by their caregivers. Lack of resources and knowledge about how to accomplish it, has been demonstrated. The objective of this study is to describe in detail the development of ActivABLES, a technical intervention to promote home-based exercise and physical activity engagement of community-dwelling stroke survivors with support from their caregivers.

METHODS

The technical development process of ActivABLES was guided by the Medical Research Council (MRC) framework for development and evaluation of complex interventions as well as by principles of human-centred design and co-design. The main steps included: (1) Synthesis of evidence supporting the inclusion of balance exercises, mobility and walking exercises and exercises for the upper arm; (2) Implementation of initial user studies with qualitative data collection from individual interviews with stroke survivors, and focus group interviews with caregivers and health professionals; (3) Preliminary testing of eight prototypes with seven stroke survivors and their caregivers.

RESULTS

After the preliminary testing of eight prototypes, four prototypes were not further developed whereas four prototypes were modified further. In addition, two new prototypes were developed, leaving six prototypes for further modification: 1) ActivFOAM for balance exercises, 2) WalkingSTARR to facilitate walking, 3) ActivBALL for hand exercises, 4) ActivSTICKS for upper arm exercises, and 5) ActivLAMP and 6) ActivTREE which both give visual feedback on progress of daily exercise and physical activities. ActivFOAM, ActivBALL and ActivSTICKS are all connected to a tablet where exercise instructions are given. All the exercise prototypes can be connected to ActivLAMP and ActivTREE to give feedback on how much exercise the user has done. Settings can be individualised and recommended daily time and/or repetition can easily be changed as the user progresses to higher activity levels.

CONCLUSIONS

The development process of ActivABLES was guided by the principles of human-centred design, with iterative testing of future users, and by the MRC framework of complex intervention, with a repeated process of development and testing. This process resulted in six prototypes which are available for feasibility testing among a small group of community-dwelling stroke survivors.

Home-based rehabilitation using smart wearable knee exercise device with electrical stimulation after anterior cruciate ligament reconstruction: A study protocol for a randomized controlled trial

INTRODUCTION

Rehabilitation after anterior cruciate ligament (ACL) reconstruction is critical to patient outcome. Despite its importance; however, hospital-based rehabilitation is limited, with barriers, including distance and cost. With recent technological advancements, wearable devices have actively been used to address these barriers. In this study, we propose a randomized controlled trial protocol investigating the efficacy and feasibility of home-based rehabilitation after ACL reconstruction using a smart wearable device providing electrical stimulation that allows knee exercise.

METHODS AND ANALYSIS

This is a protocol proposal for a prospective, single-center, randomized, controlled study. We plan to recruit adults discharged after ACL reconstruction; the recruited subjects will be randomly allocated to 1 of 2 groups, using a computer-generated randomization method: the intervention (n = 20) or control group (n = 20). The intervention group will receive a 6-week home-based rehabilitation program using smart wearable device. The control group will undergo a 6-week self-exercise program as normal. The following outcomes will be assessed at baseline, 2 weeks, and 6 weeks post the 6-week intervention program: quadriceps strength of the affect side as measured by a dynamometer (primary outcome); range of motion; root mean square of quadriceps muscle using surface electromyography; knee function using questionnaire; quality of life; subject's satisfaction score using questionnaire; frequency and duration of exercise; and knee pain. An intention-to-treat analysis will be conducted for the primary outcome.

DISCUSSION

This study is a prospective, single-center, randomized, controlled study. This study aims to research the feasibility and efficacy of a 6-week, structured home-based rehabilitation program for patients after ACL reconstruction using a smart wearable device. The findings of this study will help to establish a home-based rehabilitation program to better recovery in patients with ACL reconstruction.

TRIAL REGISTRATION NUMBER

This protocol was registered in ClinicalTrials.gov, under the number NCT04079205.

Biomedical Serious Game System for Lower Limb Motor Rehabilitation of Hemiparetic Stroke Patients

Hemiparesis resulting from a stroke has a direct impact on patients' daily activities. New approaches for motor rehabilitation include Serious Games (SG) because they include (in a motivating way) the three fundamental elements for rehabilitation: intensive, repetitive and task-oriented training. This study aims to evaluate the therapeutic effects of a biomedical SG and a scoring system developed for lower limb motor rehabilitation of hemiparetic stroke patients. The SG was inspired by the classic videogame called Pong, where the goal is to control a tennis racquet, but using muscular strength. A knee extensor apparatus was adapted with a load cell and mechanical adjustments for measuring the muscular strength of the quadriceps femoris (QFG) and hamstrings (HSG). A scoring system was proposed to evaluate muscular control. Eleven hemiparetic stroke patients participated in an exercise program using the SG twice a week for ten weeks and only the paretic side was trained. Significant Effect Sizes ( d ) were found for QFG strength ( d=0.5;p=0.021 ), QFG control ( ), HSG strength ( d=1.1; p = 0.001 ), HSG control ( d=1.5; p = 0.003 ), functional mobility ( ), gait speed ( d=0.4; p=0.007 ) and motor recovery ( ). Results indicate that the intervention of a SG with both proper apparatus and evaluation system may effectively promote lower limb motor rehabilitation of hemiparetic stroke patients.

Implementation of interactive games to a shoulder rehabilitation and evaluation system

BACKGROUND

After an operation, the shoulder and wrist might not be able to lift and swing freely, and must be assisted with rehabilitation training.

OBJECTIVE

In this paper, Kinect combined with multiple sensors of a Bluetooth ball is proposed to improve the measurement function of the arm's micro-motion trajectory, rotation amount, and acceleration, which cannot be detected by Kinect alone.

METHODS

We designed two virtual scene rehabilitation games for clinical trials. We performed validity analysis with a paired sample t-test.

RESULTS

A significance value of P*< 1 was obtained, and the arm lift angle shows an improvement from 30∘ to 60∘, indicating that the range of motion of the hand and shoulder is gradually improving.

CONCLUSION

Experiments show that virtual games combined with multiple sensors can better understand the patient's rehabilitation situation.

Effects of Video-Game Based Therapy on Balance, Postural Control, Functionality, and Quality of Life of Patients with Subacute Stroke: A Randomized Controlled Trial

Purpose

To determine the effects of a structured protocol using commercial video games on balance, postural control, functionality, quality of life, and level of motivation in patients with subacute stroke.

Methods

A randomized controlled trial was conducted. A control group (n = 25) received eight weeks of conventional rehabilitation consisting of five weekly sessions based on an approach for task-oriented motor training. The experimental group (n = 25) received eight weeks of conventional rehabilitation consisting of five weekly sessions based on an approach for task-oriented motor training. The experimental group (

Results

In the between-group comparison, statistically significant differences were observed in the Modified Rankin scores (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (p < 0.01), the Barthel Index (

Conclusion

A protocol of semi-immersive video-game based therapy, combined with conventional therapy, may be effective for improving balance, functionality, quality of life, and motivation in patients with subacute stroke. This trial is registered with NCT03528395.

Improving Maximal Strength in the Initial Postoperative Phase After Anterior Cruciate Ligament Reconstruction Surgery: Randomized Controlled Trial of an App-Based Serious Gaming Approach

Background

Anterior cruciate ligament reconstruction surgery is one of the most common orthopedic procedures. One of the main factors that influence the outcome is regaining strength in the postoperative phase. Because anterior cruciate ligament reconstruction surgeries are often performed in young patients, we combined the concept of prehabilitation with an app-based serious gaming approach to improve maximal strength postoperatively.

Objective

Our objective was to conduct a prospective randomized trial to evaluate whether an app-based active muscle training program (GenuSport Knee Trainer) can improve postoperative strength by starting rehabilitation immediately after primary anterior cruciate ligament reconstruction surgery.

Methods

We designed a pilot study in which we randomly assigned patients receiving primary anterior cruciate ligament reconstruction to either the serious gaming training (intervention) group or a conventional rehabilitation (control) group. Except for the serious gaming-based training, both groups followed the same postoperative treatment protocol. Outcome parameters were absolute and relative change in maximal strength, as well as the International Knee Documentation Committee Subjective Knee evaluation form, Knee Injury and Osteoarthritis Outcome Score, and Lysholm Knee Score.

Results

In total 26 patients agreed to participate (14 patients in the intervention group and 12 patients in the control group, 1 of whom was lost to follow-up). We noted a difference in absolute maximum strength between the exergaming intervention and the control groups. Mean maximum strength preoperatively was 155.1 (SD 79.2) N in the intervention group (n=14) and 157.0 (SD 40.8) N in the control group (n=11). Postoperative mean maximum strength was 212.8 (SD 78.5) N in the intervention group and 154.5 (SD 27.1) N in the control group. Mean absolute change in maximum strength was 57.7 (SD 95.2) N in the intervention group and –4.8 (22.2) N in the control group. The analysis of covariance model with absolute change as the dependent variable and treatment group and baseline maximum strength as covariates showed a relevant difference in relative change between treatment groups (intervention – control) of 59.7 N (95% CI 10.1-109.3; P=.02). Similarly to the absolute increase, the relative change in maximum strength was relevantly higher in the exergaming group. The mean relative change in maximum strength was 1.7 (SD 1.17) in the intervention group and 1 (SD 0.13) in the control group. No adverse events or problems were reported during the study period.

Conclusions

Implementation of an app-based active muscle training program in the early postoperative therapy scheme was associated with an improvement in maximal strength. Therefore, we considered the use of GenuSport training after anterior cruciate ligament reconstruction to be a helpful complement to rehabilitation after anterior cruciate ligament reconstruction surgery to improve strength in the early postoperative phase. To our knowledge this was the first study to analyze immediate postoperative serious gaming-based training with the GenuSport device based on strength improvement.

Can the Wii Fit Balance Board be Used as a Fall Risk Assessment Tool among Poststroke Patients?

BACKGROUND

The prevalence of falls can be as high as 73% in the stroke population. Falls occur as a result of multiple factors. Factors such as balance impairments can be improved through physical therapy intervention. However, insurance payers limit the number of visits per patient. It is crucial to find other ways to assess balance after discharge from rehabilitation.

PURPOSE

The purpose of this study is to determine if the Nintendo Wii Fit can be used as a fall risk assessment tool among the poststroke population.

METHODOLOGY

A sample of 11 stroke survivors were recruited (mean age 63.36 years). Each participant completed a balance and fall risk assessment using the Berg Balance Scale, Timed Up & Go, Four Square Step Test, Five Times Sit-to-Stand and 8-Foot Walk Test. Bivariate correlation will examine the validity of the Nintendo Wii Fit as a fall risk assessment tool in this population.

RESULTS

The Nintendo Wii Fit Balance Test was found to be correlated with gait speed measured by the 8-Foot Walk Test. There is no correlation between the Wii Fit Balance Tests and most common standardized fall risk measures. Standardized fall risk outcome measures also significantly correlate with each other.

CONCLUSIONS

The study suggests that while there is a potential utility of the game system to be used at home by patient and caregivers, the Wii Fit Balance Test may not be an appropriate substitute to the standardized fall risk assessment tool for stroke patients in the clinical setting.

Interaction Modalities Used on Serious Games for Upper Limb Rehabilitation: A Systematic Review

This systematic review aims to analyze the state-of-the-art regarding interaction modalities used on serious games for upper limb rehabilitation. A systematic search was performed in IEEE Xplore and Web of Science databases. PRISMA and QualSyst protocols were used to filter and assess the articles. Articles must meet the following inclusion criteria: they must be written in English; be at least four pages in length; use or develop serious games; focus on upper limb rehabilitation; and be published between 2007 and 2017. Of 121 articles initially retrieved, 33 articles met the inclusion criteria. Three interaction modalities were found: vision systems (42.4%), complementary vision systems (30.3%), and no-vision systems (27.2%). Vision systems and no-vision systems obtained a similar mean QualSyst (86%) followed by complementary vision systems (85.7%). Almost half of the studies used vision systems as the interaction modality (42.4%) and used the Kinect sensor to collect the body movements (48.48%). The shoulder was the most treated body part in the studies (19%). A key limitation of vision systems and complementary vision systems is that their device performances might be affected by lighting conditions. A main limitation of the no-vision systems is that the range-of-motion in angles of the body movement might not be measured accurately. Due to a limited number of studies, fruitful areas for further research could be the following: serious games focused on finger rehabilitation and trauma injuries, game difficulty adaptation based on user's muscle strength and posture, and multisensor data fusion on interaction modalities.

What is the impact of user affect on motor learning in virtual environments after stroke? A scoping review

PURPOSE

The purported affective impact of virtual reality (VR) and active video gaming (AVG) systems is a key marketing strategy underlying their use in stroke rehabilitation, yet little is known as to how affective constructs are measured or linked to intervention outcomes. The purpose of this scoping review is to 1) explore how motivation, enjoyment, engagement, immersion and presence are measured or described in VR/AVG interventions for patients with stroke; 2) identify directional relationships between these constructs; and 3) evaluate their impact on motor learning outcomes.

METHODS

A literature search was undertaken of VR/AVG interventional studies for adults post-stroke published in Medline, PEDro and CINAHL databases between 2007 and 2017. Following screening, reviewers used an iterative charting framework to extract data about construct measurement and description. A numerical and thematic analytical approach adhered to established scoping review guidelines.

RESULTS

One hundred fifty-five studies were included in the review. Although the majority (89%; N = 138) of studies described at least one of the five constructs within their text, construct measurement took place in only 32% (N = 50) of studies. The most frequently described construct was motivation (79%, N = 123) while the most frequently measured construct was enjoyment (27%, N = 42). A summative content analysis of the 50 studies in which a construct was measured revealed that constructs were described either as a rationale for the use of VR/AVGs in rehabilitation (76%, N = 38) or as an explanation for intervention results (56%, N = 29). 38 (76%) of the studies proposed relational links between two or more constructs and/or between any construct and motor learning. No study used statistical analyses to examine these links.

CONCLUSIONS

Results indicate a clear discrepancy between the theoretical importance of affective constructs within VR/AVG interventions and actual construct measurement. Standardized terminology and outcome measures are required to better understand how enjoyment, engagement, motivation, immersion and presence contribute individually or in interaction to VR/AVG intervention effectiveness.

Assistive game controller for artificial intelligence-enhanced telerehabilitation post-stroke

Off-the-shelf gaming technology is designed for young, fit, and motor intact individuals. Artificial intelligence (AI) has a role in making controllers and therapeutic games adaptable to the disabled. Post-stroke rehabilitation outcomes can be enhanced by gaming technology within the home to enable engaging telerehabilitation. BrightBrainer™ Grasp (BBG) is a novel therapeutic game controller designed to adapt to arm and hand impairments post-stroke. It mediates intensive arm reach, grasp and finger extension training and has the ability to track relevant outcomes. The newly designed controller uses BrightBrainer gamification system with AI technology to provide automatic adaptation, requiring minimal clinician input. This article describes the BBG design, hardware, force and movement detection and calibration, and its integration with the therapeutic games. The use of AI in adapting a library of custom therapeutic games is also described. Results of a usability study with healthy individuals and related design modifications are presented, with implications for future trials.

Real-time Video Projection in an MRI for Characterization of Neural Correlates Associated with Mirror Therapy for Phantom Limb Pain

Mirror therapy (MT) has been proposed as an effective rehabilitative strategy to alleviate pain symptoms in amputees with phantom limb pain (PLP). However, establishing the neural correlates associated with MT therapy have been challenging given that it is difficult to administer the therapy effectively within a magnetic resonance imaging (MRI) scanner environment. To characterize the functional organization of cortical regions associated with this rehabilitative strategy, we have developed a combined behavioral and functional neuroimaging protocol that can be applied in participants with a leg amputation. This novel approach allows participants to undergo MT within the MRI scanner environment by viewing real-time video images captured by a camera. The images are viewed by the participant through a system of mirrors and a monitor that the participant views while lying on the scanner bed. In this manner, functional changes in cortical areas of interest (e.g., sensorimotor cortex) can be characterized in response to the direct application of MT.

Test-Retest Reliability and Clinical Feasibility of a Motion-Controlled Game to Enhance the Literacy and Numeracy Skills of Young Individuals with Intellectual Disability

Games using motion capture from web cameras have become increasingly popular. However, there are no games specifically designed to teach literacy to individuals with intellectual disabilities (ID). The aim of this study was to investigate the feasibility of introducing young individuals with ID to a new augmented reality game, the MoviLetrando, and establish its test-retest reliability to determine its usefulness in teaching the alphabet and motor control skills. The performance of a sample of 88 ID participants (52 males, 36 females, mean ± standard deviation age, 11.2 ± 2.6 years) was measured on two different testing sessions. Five dependent variables (total points, number of correct vowels/numbers, number of mistakes, number of omissions, and average time to reach symbols) were used for data analysis. The intraclass correlation coefficient (ICC), standard error of measurement (SEM), Cronbach's alpha, and Bland-Altman plots were used to estimate the test-retest reliability and measurement precision. Feasibility was assessed by examining recruitment, adherence, and acceptability in both phases of the game. The dependent variables identified in the MoviLetrando demonstrated an ICC of 0.44 to 0.82, suggesting acceptable/good test-retest reliability, respectively. The internal consistency was satisfactory. The small SEM, as well as the narrow width of the 95 percent limits of agreement in the Bland-Altman plots, implied that measurements of these dependent variables were precise and accurate on both the occasions. Excellent test-retest reliability for performance measurement was demonstrated in the ID participants, indicating that the MoviLetrando could be used as an outcome measure for this population.

Virtual Reality in Upper Extremity Rehabilitation of Stroke Patients: A Randomized Controlled Trial

OBJECTIVE

Virtual reality game system is one of novel approaches, which can improve hemiplegic extremity functions of stroke patients. We aimed to evaluate the effect of the Microsoft Xbox 360 Kinect video game system on upper limb motor functions for subacute stroke patients.

METHODS

The study included 42 stroke patients of which 35 (19 Virtual reality group, 16 control group) completed the study. All patients received 60 minutes of conventional therapy for upper extremity, 5 times per-week for 4 weeks. Virtual reality group additionally received Xbox Kinect game system 30 minutes per-day. Patients were evaluated prior to the rehabilitation and at the end of 4 weeks. Box&Block Test, Functional independence measure self-care score, Brunnstorm stage and Fugl-Meyer upper extremity motor function scale were used as outcome measures.

RESULTS

The Brunnstrom stages and the scores on the Fugl-Meyer upper extremity, Box&Block Test and Functional independence measure improved significantly from baseline to post-treatment in both the experimental and the control groups. The Brunnstrom stage-upper extremity and Box&Block Test gain for the experimental group were significantly higher compared to the control group, while the Brunnstrom stage-hand, the Functional independence measure gain and Fugl-Meyer gain were similar between the groups.

CONCLUSIONS

We found evidence that kinect-based game system in addition to conventional therapy may have supplemental benefit for stroke patients. However, for virtual reality game systems to enter the routine practice of stroke rehabilitation, randomized controlled clinical trials with longer follow-up periods and larger sample sizes are needed especially to determine an optimal duration and intensity of the treatment.

Developing a Suite of Motion-Controlled Games for Upper Extremity Training in Children with Cerebral Palsy: A Proof-of-Concept Study

Aim: The Scratch programming language allows learner developers to write games. The Kinect2Scratch extension makes Scratch games with bodily motion control possible by connecting to Microsoft's Kinect sensor. This study examined the feasibility and possible efficacy of a suite of motion-controlled games designed for upper extremity (UE) training in children with cerebral palsy (CP) using Kinect2Scratch.

Materials and Methods: This is a proof-of-concept study. We developed three games, requiring three UE movement patterns (shoulder holding, reaching, and handclap), for use in children with CP. The primary outcome was feasibility, addressed by adherence, engagement, satisfaction, and safety. The secondary outcome was efficacy, which was evaluated by Quality of Upper Extremities Skills Test (QUEST), Box and Block Test (BBT), Melbourne Assessment 2 (MA2) test, and ABILHAND-kids score.

Results: Thirteen children with CP (mean age 6.9 years) received 24 sessions of training (30 minutes per session). The adherence rate was 100%. During the first 2 weeks of training, children had a significantly higher level of participation in Kinect2Scratch training than in conventional rehabilitation [Pittsburgh Participation Scale, median (interquartile range [IQR]), 6 (3–6) vs. 4 (3–6) P = 0.04]. However, during the last 2 weeks of training, there was no significant difference in participation between the Kinect2Scratch and conventional training [Pittsburgh Rehabilitation Participation Scale, median (IQR), 4 (3–5) vs. 4 (3–6) P = 0.55]. Most children enjoyed playing the games. The mean score of enjoyment was 4.54 ± 0.66. There were no adverse events during the training periods. The children had significant improvement in total score of QUEST and MA2. There were no significant improvements in BBT and ABILHAND-kids score.

Conclusion: Using Kinect2Scratch games for UE training is a feasible adjunctive program for children with CP.

Investigating the Usability and Acute Effects of a Bedside Video Console to Prefrontal Cortical Activity Alterations: A Preclinical Study in Healthy Elderly

Elderly people at risk of developing cognitive decline; e.g., following surgery, may benefit from structured, challenging, and repetitive cognitive video training. This study assessed usability and acute effects of a newly developed bedside console (COPHYCON). Fifteen healthy elderly individuals performed a one-time 80-min intervention, including cognitive video games aimed at improving awareness and selective attention. Perceived usefulness and perceived ease of use (Technology Acceptance Model) were assessed together with measures of the achieved game level, reaction times, (in-) correct responses during ALERT and SELECT game play. Further, prefrontal cortical involvement of the regional cerebral hemoglobin saturation (rS02%) assessed with functional near infrared spectroscopy (fNIRS) (n = 5) and EEG power (n = 10) was analyzed. All participants completed the study without any adverse events. Perceived usefulness and perceived ease of use (TAM scores range 1-7) of the system varied between 3.9 and 6.3. The game levels reached for awareness varied between 9 and 11 (initial score 8-10), for reaction speed between 439 and 469 ms, and for correct responses between 74.1 and 78.8%. The highest level for the selective attention games was 2 (initial score 1), where reaction speed varied between 439 and 469 ms, correct responses between 96.2 and 98.5%, respectively. The decrease of rS02% in the right prefrontal cortex during gameplay was significantly (p < 0.001) lower, compared to the left prefrontal cortex. Four participants yielded significant lower rS02% measures after exergaming with the ALERT games (p < 0.000), but not with the SELECT games. EEG recordings of theta power significantly decreased in the averaged ~0.25-0.75 time interval for the left prefrontal cortex sensor across the cognitive game levels between the ALERT 1 and SELECT 1, as well as between SELECT 1 and 2 games. Participants rated the usability of the COPHYCON training positively. Further results indicate that video gaming may be an effective measure to affect prefrontal cortical functioning in elderly. The results warrant a clinical explorative study investigating the feasibility of the COPHYCON in a clinical setting.

Virtual reality for stroke rehabilitation

BACKGROUND

Virtual reality and interactive video gaming have emerged as recent treatment approaches in stroke rehabilitation with commercial gaming consoles in particular, being rapidly adopted in clinical settings. This is an update of a Cochrane Review published first in 2011 and then again in 2015.

OBJECTIVES

Primary objective: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on upper limb function and activity.Secondary objectives: to determine the efficacy of virtual reality compared with an alternative intervention or no intervention on: gait and balance, global motor function, cognitive function, activity limitation, participation restriction, quality of life, and adverse events.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2017), CENTRAL, MEDLINE, Embase, and seven additional databases. We also searched trials registries and reference lists.

SELECTION CRITERIA

Randomised and quasi-randomised trials of virtual reality ("an advanced form of human-computer interface that allows the user to 'interact' with and become 'immersed' in a computer-generated environment in a naturalistic fashion") in adults after stroke. The primary outcome of interest was upper limb function and activity. Secondary outcomes included gait and balance and global motor function.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials based on pre-defined inclusion criteria, extracted data, and assessed risk of bias. A third review author moderated disagreements when required. The review authors contacted investigators to obtain missing information.

MAIN RESULTS

We included 72 trials that involved 2470 participants. This review includes 35 new studies in addition to the studies included in the previous version of this review. Study sample sizes were generally small and interventions varied in terms of both the goals of treatment and the virtual reality devices used. The risk of bias present in many studies was unclear due to poor reporting. Thus, while there are a large number of randomised controlled trials, the evidence remains mostly low quality when rated using the GRADE system. Control groups usually received no intervention or therapy based on a standard-care approach.

PRIMARY OUTCOME

results were not statistically significant for upper limb function (standardised mean difference (SMD) 0.07, 95% confidence intervals (CI) -0.05 to 0.20, 22 studies, 1038 participants, low-quality evidence) when comparing virtual reality to conventional therapy. However, when virtual reality was used in addition to usual care (providing a higher dose of therapy for those in the intervention group) there was a statistically significant difference between groups (SMD 0.49, 0.21 to 0.77, 10 studies, 210 participants, low-quality evidence).

SECONDARY OUTCOMES

when compared to conventional therapy approaches there were no statistically significant effects for gait speed or balance. Results were statistically significant for the activities of daily living (ADL) outcome (SMD 0.25, 95% CI 0.06 to 0.43, 10 studies, 466 participants, moderate-quality evidence); however, we were unable to pool results for cognitive function, participation restriction, or quality of life. Twenty-three studies reported that they monitored for adverse events; across these studies there were few adverse events and those reported were relatively mild.

AUTHORS' CONCLUSIONS

We found evidence that the use of virtual reality and interactive video gaming was not more beneficial than conventional therapy approaches in improving upper limb function. Virtual reality may be beneficial in improving upper limb function and activities of daily living function when used as an adjunct to usual care (to increase overall therapy time). There was insufficient evidence to reach conclusions about the effect of virtual reality and interactive video gaming on gait speed, balance, participation, or quality of life. This review found that time since onset of stroke, severity of impairment, and the type of device (commercial or customised) were not strong influencers of outcome. There was a trend suggesting that higher dose (more than 15 hours of total intervention) was preferable as were customised virtual reality programs; however, these findings were not statistically significant.

Systematic Review on the Effects of Serious Games and Wearable Technology Used in Rehabilitation of Patients With Traumatic Bone and Soft Tissue Injuries

OBJECTIVE

To assess the effects on functional outcomes and treatment adherence of wearable technology and serious games (ie, interactive computer applications with specific purposes useful in the "real world") currently used in physical rehabilitation of patients after traumatic bone and soft tissue injuries.

DATA SOURCES

PubMed, EMBASE, Cochrane Library, and Current Index to Nursing and Allied Health Literature were searched without publication date restrictions for the terms wearable, serious game, videogame or mobile application, and rehabilitation, exercise therapy, and physiotherapy.

STUDY SELECTION

The search yielded 2704 eligible articles, which were screened by 2 independent reviewers. Studies comparing serious games to standard therapy were included.

DATA EXTRACTION

Methodology and results of the studies were critically appraised in conformity with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SYNTHESIS

Twelve articles were included, all of which tested "off-the-shelf" games. No studies on "wearable-controlled" games or games specifically developed for rehabilitation could be included. Medical conditions included postoperative rehabilitation and acute traumatic injuries. All studies were of low to moderate quality. Only 2 studies found beneficial effects of serious games compared to conventional therapy. One of 3 studies reporting pain scores found beneficial effects of serious games compared to physiotherapy. One of 5 trials reporting treatment adherence found a statistically significant advantage in the game group compared to conventional physiotherapy. Because of heterogeneity in study design and outcome measures, pooling of data was not possible.

CONCLUSIONS

Serious games seem a safe alternative or addition to conventional physiotherapy after traumatic bone and soft tissue injuries. Future research should determine their validity and effectiveness in rehabilitation therapy, next to their cost-effectiveness and effect on treatment adherence.

Reported use of technology in stroke rehabilitation by physical and occupational therapists

PURPOSE

With the patient care experience being a healthcare priority, it is concerning that patients with stroke reported boredom and a desire for greater fostering of autonomy, when evaluating their rehabilitation experience. Technology has the potential to reduce these shortcomings by engaging patients through entertainment and objective feedback. Providing objective feedback has resulted in improved outcomes and may assist the patient in learning how to self-manage rehabilitation. Our goal was to examine the extent to which physical and occupational therapists use technology in clinical stroke rehabilitation home exercise programs.

MATERIALS AND METHODS

Surveys were sent via mail, email and online postings to over 500 therapists, 107 responded.

RESULTS

Conventional equipment such as stopwatches are more frequently used compared to newer technology like Wii and Kinect games. Still, less than 25% of therapists' report using a stopwatch five or more times per week. Notably, feedback to patients is based upon objective data less than 50% of the time by most therapists. At the end of clinical rehabilitation, patients typically receive a written home exercise program and non-technological equipment, like theraband and/or theraputty to continue rehabilitation efforts independently.

CONCLUSIONS

The use of technology is not pervasive in the continuum of stroke rehabilitation. Implications for Rehabilitation The patient care experience is a priority in healthcare, so when patients report feeling bored and desiring greater fostering of autonomy in stroke rehabilitation, it is troubling. Research examining the use of technology has shown positive results for improving motor performance and engaging patients through entertainment and use of objective feedback. Physical and occupational therapists do not widely use technology in stroke rehabilitation. Therapists should consider using technology in stroke rehabilitation to better meet the needs of the patient.

Rehabilitation-Oriented Serious Game Development and Evaluation Guidelines for Musculoskeletal Disorders

Background

The progress in information and communication technology (ICT) led to the development of a new rehabilitation technique called “serious game for functional rehabilitation.” Previous works have shown that serious games can be used for general health and specific disease management. However, there is still lack of consensus on development and evaluation guidelines. It is important to note that the game performance depends on the designed scenario.

Objective

The objective of this work was to develop specific game scenarios and evaluate them with a panel of musculoskeletal patients to propose game development and evaluation guidelines.

Methods

A two-stage workflow was proposed using determinant framework. The development guideline includes the selection of three-dimensional (3D) computer graphics technologies and tools, the modeling of physical aspects, the design of rehabilitation scenarios, and the implementation of the proposed scenarios. The evaluation guideline consists of the definition of evaluation metrics, the execution of the evaluation campaign, the analysis of user results and feedbacks, and the improvement of the designed game.

Results

The case study for musculoskeletal disorders on the healthy control and patient groups showed the usefulness of these guidelines and associated games. All participants enjoyed the 2 developed games (football and object manipulation), and found them challenging and amusing. In particular, some healthy subjects increased their score when enhancing the level of difficulty. Furthermore, there were no risks and accidents associated with the execution of these games.

Conclusions

It is expected that with the proven effectiveness of the proposed guidelines and associated games, this new rehabilitation game may be translated into clinical routine practice for the benefit of patients with musculoskeletal disorders.

Matrix Metalloproteinases, Neural Extracellular Matrix, and Central Nervous System Pathology

The functionality and stability of the central nervous system (CNS) pabulum, called neural extracellular matrix (nECM), is paramount for the maintenance of a healthy network. The loosening or the damage of the scaffold disrupts synaptic transmission with the consequent imbalance of the neurotransmitters, reactive cells invasion, astrocytosis, new matrix deposition, digestion of the previous structure and ultimately, maladaptive plasticity with the loss of neuronal viability. nECM is constantly affected by CNS disorders, particularly in chronic modifying such as neurodegenerative disease, or in acute/subacute with chronic sequelae, like cerebrovascular and inflammatory pathology. Matrix metalloproteinases (MMPs) are the main interfering agent of nECM, guiding the balance of degradation and new deposition of proteins such as proteoglycans and glycoproteins, or glycosaminoglycans, such as hyaluronic acid. Activation of these enzymes is modulated by their physiologic inhibitors, the tissue inhibitors of MMPs or via other proteases inhibitors, as well as genetic or epigenetic up- or downregulation through molecular interaction or receptor activation. The appropriate understanding of the pathways underlying nECM modifications in CNS pathology is probably one of the pivotal future directions to identify the healthy brain network and subsequently design new therapies to interfere with the progression of the CNS disease and eventually find appropriate therapies.

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.

A Mixed Methods Small Pilot Study to Describe the Effects of Upper Limb Training Using a Virtual Reality Gaming System in People with Chronic Stroke

Introduction. This small pilot study aimed to examine the feasibility of an upper limb rehabilitation system (the YouGrabber) in a community rehabilitation centre, qualitatively explore participant experiences, and describe changes after using it. Methods and Material. Chronic stroke participants attending a community rehabilitation centre in the UK were randomised to either a YouGrabber or a gym group and completed 18 training sessions over 12 weeks. The motor activity log, box and block, and fatigue severity score were administered by a blinded assessor before and after the intervention. Semistructured interviews were used to ascertain participants' views about using the YouGrabber. Results. Twelve participants (6 females) with chronic stroke were recruited. All adhered to the intervention. There were no adverse events, dropouts, or withdrawal. There were no significant differences between the YouGrabber and gym groups although there were significant within group improvements on the motor activity log (median change: 0.59, range: 0.2–1.25; p < 0.05) within the YouGrabber group. Participants reported that the YouGrabber was motivational but they expressed frustration with technical challenges. Conclusions. The YouGrabber appeared practical and may improve upper limb activities in people several months after stroke. Future work could examine cognition, cost effectiveness, and different training intensities.

Effect of Virtual Reality-based Bilateral Upper Extremity Training on Upper Extremity Function after Stroke: A Randomized Controlled Clinical Trial

In the present study, we aimed to investigate the effect of virtual reality-based bilateral upper extremity training (VRBT) on paretic upper limb function and muscle strength in patients with stroke. Eighteen stroke survivors were assigned to either the VRBT group (n = 10) or the bilateral upper limb training group (BT, n = 8). Patients in the VRBT group performed bilateral upper extremity exercises in a virtual reality environment, whereas those in the BT group performed conventional bilateral upper extremity exercises. All training was conducted for 30 minutes day^-1 , 3 days a week, for a period of 6 weeks. Patients were assessed for upper extremity function and hand strength. Compared with the BT group, the VRBT group exhibited significant improvements in upper extremity function and muscle strength (p < 0.05) after the 6-week training programme. The Box and Block test results revealed that upper extremity function and elbow flexion in hand strength were significantly improved in terms of group, time and interaction effect of group by time. Furthermore, the VRBT group demonstrated significant improvements in upper extremity function, as measured by the Jebsen Hand Function Test and Grooved Pegboard test, and in the hand strength test, as measured by elbow extension, grip, palmar pinch, lateral pinch and tip pinch, in both time and the interaction effect of group by time. These results suggest that VRBT is a feasible and beneficial means of improving upper extremity function and muscle strength in individuals following stroke. Copyright © 2016 John Wiley & Sons, Ltd.

Does a Combination of Virtual Reality, Neuromodulation and Neuroimaging Provide a Comprehensive Platform for Neurorehabilitation? - A Narrative Review of the Literature

In the last decade, virtual reality (VR) training has been used extensively in video games and military training to provide a sense of realism and environmental interaction to its users. More recently, VR training has been explored as a possible adjunct therapy for people with motor and mental health dysfunctions. The concept underlying VR therapy as a treatment for motor and cognitive dysfunction is to improve neuroplasticity of the brain by engaging users in multisensory training. In this review, we discuss the theoretical framework underlying the use of VR as a therapeutic intervention for neurorehabilitation and provide evidence for its use in treating motor and mental disorders such as cerebral palsy, Parkinson’s disease, stroke, schizophrenia, anxiety disorders, and other related clinical areas. While this review provides some insights into the efficacy of VR in clinical rehabilitation and its complimentary use with neuroimaging (e.g., fNIRS and EEG) and neuromodulation (e.g., tDCS and rTMS), more research is needed to understand how different clinical conditions are affected by VR therapies (e.g., stimulus presentation, interactivity, control and types of VR). Future studies should consider large, longitudinal randomized controlled trials to determine the true potential of VR therapies in various clinical populations.

Which is better in the rehabilitation of stroke patients, core stability exercises or conventional exercises?

[Purpose] The aim of this study was to determine which is better in the rehabilitation of stroke patients, core stability exercises or conventional exercises. [Subjects and Methods] Forty participants with hemiplegia were recruited in the Department of Neurology of Yidu Central Hospital of Weifang between January 2014 and February 2015 and randomly divided into either an experimental or control group. The patients in the control group performed conventional exercises for six weeks, and those in the experiment group performed core stability exercises for six weeks. The outcomes were evaluated using Modified Barthel Index and Berg Balance Scale. [Results] After treatment, the Modified Barthel Index and Berg Balance Scale were significantly increased in both groups when compared with the baseline. The Modified Barthel Index was significantly lower in the control group compared with the experimental group. The Berg Balance Scale scores in the control group were relatively lower than those in the experimental group, but there was no significant difference between the two groups. [Conclusion] Core stability exercises have a better effect on patients with hemiplegia than conventional exercises.

Acceptance of Serious Games in Psychotherapy: An Inquiry into the Stance of Therapists and Patients

BACKGROUND

Serious games are computer or video games that contain elements that are specifically designed for the purpose of education or training. Serious games are increasingly being used within healthcare, but their introduction into and application in psychotherapeutic settings as an e-mental health treatment modality raises questions for both patients and therapists. Current research demonstrates the potential role and effectiveness of serious games within a psychotherapeutic context. However, a limited understanding of patients' and therapists' existing knowledge and experience of serious games, as well as of their readiness to utilize and apply them for the treatment of psychological conditions, requires further investigation.

MATERIALS AND METHODS

Acceptance, experience, and requirements for the utilization of serious games in therapeutic contexts were assessed through online surveys with German-speaking patients (n = 260) and psychotherapists (n = 234). Respondents' answers were analyzed by a combination of descriptive and inferential statistics by using SPSS.

RESULTS

Current knowledge regarding serious games was very limited, with only 10.4% of patients and 11.5% of therapists reporting existing knowledge. However, a general openness toward the concept was observed: 88% of patients and 90% of therapists could envisage a therapeutic use. Patients (rs = 0.169, p = 0.006) who self-rated their level of computer and video game expertise as high were more likely to consider use within psychotherapy, compared with patients who self-rated their expertise as low. Therapists who currently play computer and video games perceive fewer disadvantages of serious game application in a psychotherapeutic context (p = 0.097). Consideration of serious game use was differentiated by the therapeutic approach (p = 0.003), specific mental disorders (highest rated relevant cases: anxiety disorders, affective disorders, disorders regarding impulse control, and adjustment disorders), and patient age (i.e., use with young adults was deemed the most appropriate by 91.8% of therapists).

CONCLUSION

The application of serious games is conceivable for patients and therapists, especially as a complementary element to traditional face-to-face psychotherapy. Acceptance is strongly related to therapeutic context. Only a small number of therapists and patients agree on the possibility of using a serious game instead of face-to-face therapy.

Feasibility of Using Tetrax Biofeedback Video Games for Balance Training in Patients With Chronic Hemiplegic Stroke

BACKGROUND

Decreased weight bearing on the affected lower limb and poor weight shifting are common after a stroke occurs. The Tetrax biofeedback system is a center-of-pressure controlled video game system designed for patients with balance deficits. Although it is a commercial product, information about its clinical use for patients affected by stroke is limited.

OBJECTIVE

To investigate the feasibility and potential efficacy of the Tetrax biofeedback system for balance training in patients with chronic stroke.

DESIGN

Feasibility study.

SETTING

Rehabilitation department of a medical center.

PARTICIPANTS

Participants who had sustained a hemiplegic stroke at least 6 months prior to enrollment but were still able to stand independently for more than 5 minutes.

METHODS

Participants were randomly assigned to an intervention group (IG) or control group (CG). All participants received conventional rehabilitation training. The IG also received 20 minutes of exposure to Tetrax biofeedback games controlled by change in center of pressure 3 times a week for 6 weeks.

MAIN OUTCOME MEASUREMENTS

The primary outcome was feasibility, addressed by adherence, safety, and satisfaction. The secondary outcome was efficacy, which was evaluated by the subtests of physiological profile assessment, posturography, Timed Up and Go, and Forward Reach tests. We used percentage change (post-training score - pretraining score/pretraining score) to quantify the intervention effects. Mann-Whitney U tests were used to analyze differences in percentage of change between groups.

RESULTS

A total of 14 participants were assigned to the IG, and 13 were assigned to the CG; 12 participants in the IG and 11 in the CG completed the study. In the IG group, those who completed the 6-week intervention attended 89.5% of planned sessions. No major adverse events or falls occurred within the intervention sessions. With use of 5-point Likert scales, participants rated their enjoyment of Tetrax games as 4.33 ± 0.78, their motivation as 4.17 ± 1.03, and perceived helpfulness as 4.25 ± 0.97. The IG demonstrated a significantly greater improvement in reaction time (P = .002), proprioception (P < .001), symmetric weight bearing (P = .027), Timed Up and Go (P < .001), and Forward Reach (P < .001) compared with the CG.

CONCLUSIONS

Using Tetrax biofeedback video games for balance training is a feasible adjunctive program that may augment conventional therapy in persons affected by chronic hemiplegic stroke.

LEVEL OF EVIDENCE

II.

Kinect-Based Sliding Mode Control for Lynxmotion Robotic Arm

Recently, the technological development of manipulator robot increases very quickly and provides a positive impact to human life. The implementation of the manipulator robot technology offers more efficiency and high performance for several human’s tasks. In reality, efforts published in this context are focused on implementing control algorithms with already preprogrammed desired trajectories (passive robots case) or trajectory generation based on feedback sensors (active robots case). However, gesture based control robot can be considered as another channel of system control which is not widely discussed. This paper focuses on a Kinect-based real-time interactive control system implementation. Based on LabVIEW integrated development environment (IDE), a developed human-machine-interface (HMI) allows user to control in real time a Lynxmotion robotic arm. The Kinect software development kit (SDK) provides a tool to keep track of human body skeleton and abstract it into 3-dimensional coordinates. Therefore, the Kinect sensor is integrated into our control system to detect the different user joints coordinates. The Lynxmotion dynamic has been implemented in a real-time sliding mode control algorithm. The experimental results are carried out to test the effectiveness of the system, and the results verify the tracking ability, stability, and robustness.