Commercial gaming devices for stroke upper limb rehabilitation: a survey of current practice

Examining Usability, Acceptability, and Adoption of a Self-Directed, Technology-Based Intervention for Upper Limb Rehabilitation After Stroke: Cohort Study

BACKGROUND

Upper limb (UL) recovery after stroke is strongly dependent upon rehabilitation dose. Rehabilitation technologies present pragmatic solutions to dose enhancement, complementing therapeutic activity within conventional rehabilitation, connecting clinicians with patients remotely, and empowering patients to drive their own recovery. To date, rehabilitation technologies have been poorly adopted. Understanding the barriers to adoption may shape strategies to enhance technology use and therefore increase rehabilitation dose, thus optimizing recovery potential.

OBJECTIVE

We examined the usability, acceptability, and adoption of a self-directed, exercise-gaming technology within a heterogeneous stroke survivor cohort and investigated how stroke survivor characteristics, technology usability, and attitudes toward technology influenced adoption.

METHODS

A feasibility study of a novel exercise-gaming technology for self-directed UL rehabilitation in early subacute stroke survivors (N=30) was conducted in an inpatient, acute hospital setting. Demographic and clinical characteristics were recorded; participants' performance in using the system (usability) was assessed using a 4-point performance rating scale (adapted from the Barthel index), and adherence with the system was electronically logged throughout the trial. The technology acceptance model was used to formulate a survey examining the acceptability of the system. Spearman rank correlations were used to examine associations between participant characteristics, user performance (usability), end-point technology acceptance, and intervention adherence (adoption).

RESULTS

The technology was usable for 87% (n=26) of participants, and the overall technology acceptance rating was 68% (95% CI 56%-79%). Participants trained with the device for a median of 26 (IQR 16-31) minutes daily over an enrollment period of 8 (IQR 5-14) days. Technology adoption positively correlated with user performance (usability) (ρ=0.55; 95% CI 0.23-0.75; P=.007) and acceptability as well as domains of perceived usefulness (ρ=0.42; 95% CI 0.09-0.68; P=.03) and perceived ease of use (ρ=0.46; 95% CI 0.10-0.74; P=.02). Technology acceptance decreased with increased global stroke severity (ρ=-0.56; 95% CI -0.79 to -0.22; P=.007).

CONCLUSIONS

This technology was usable and acceptable for the majority of the cohort, who achieved an intervention dose with technology-facilitated, self-directed UL training that exceeded conventional care norms. Technology usability and acceptability were determinants of adoption and appear to be mediated by stroke severity. The results demonstrate the importance of selecting technologies for stroke survivors on the basis of individual needs and abilities, as well as optimizing the accessibility of technologies for the target user group. Facilitating changes in stroke survivors' beliefs and attitudes toward rehabilitation technologies may enhance adoption. Further work is needed to understand how technology can be optimized to benefit those with more severe stroke.

Feasibility of a serious game system including a tangible object for post stroke upper limb rehabilitation: a pilot randomized clinical study

Introduction

Serious games can be used to provide intensive rehabilitation through attractive exercises as part of post-stroke rehabilitation. However, currently available commercial and serious games systems primarily train shoulder and elbow movements. These games lack the grasping and displacement components that are essential to improve upper limb function. For this reason, we developed a tabletop device that encompassed a serious game with a tangible object to rehabilitate combined reaching and displacement movements: the Ergotact system.

Objectives

The aim of this pilot study was to assess the feasibility and the short-term effects of a training program using the Ergotact prototype in individuals with chronic stroke.

Methods

Participants were assigned to one of two groups: a serious game training group (Ergotact) or a control training group (Self).

Results

Twenty-eight individuals were included. Upper limb function increased after the Ergotact training program, although not statistically significantly, and the program did not induce pain or fatigue, demonstrating its safety.

Conclusion

The Ergotact system for upper limb rehabilitation was well accepted and induced participant satisfaction. It complies with current recommendations for people with stroke to autonomously perform intensive active exercises in a fun context, in addition to conventional rehabilitation sessions with therapists.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT03166020?term=NCT03166020&draw=2&rank=1, identifier NCT03166020.

A focus group study of therapists' views on using a novel neuroanimation virtual reality game to deliver intensive upper-limb rehabilitation early after stroke

BACKGROUND

Intensive training can significantly reduce upper-limb impairments after stroke but delivering interventions of sufficiently high intensity is extremely difficult in routine practice. The MindPod Dolphin® system is a novel neuroanimation experience which provides motivating and intensive virtual reality based training for the upper-limb. However several studies report that health professionals have reservations about using technology in rehabilitation. Therefore, this study sought to explore the views of therapists who had used this novel neuroanimation therapy (NAT) in a clinical centre to deliver intensive for the upper-limb of people after stroke in a phase 2 trial (SMARTS2).

METHODS

Four therapists (three female, two physical and two occupational therapists) who delivered NAT participated in a focus group conducted by two independent researchers. The theoretical domains framework and COM-B behaviour change models informed the discussion schedule for the focus group. An inductive approach to content analysis was used. Recordings were transcribed, coded and thematically analysed. Generated key themes were cross-checked with participants.

RESULTS

Whilst therapists had some initial concerns about using NAT, these were reduced by training, reference materials and face-to-face technical support. Therapists noted several significant benefits to using NAT including multi-system involvement, carry-over to functional tasks and high levels of patient engagement.

CONCLUSIONS

These findings illuminate key areas that clinicians, technology developers and researchers should consider when designing, developing and implementing NAT. Specifically, they highlight the importance of planning the implementation of rehabilitation technologies, ensuring technologies are robust and suggest a range of benefits that might be conferred to patients when using intensive NAT as part of rehabilitation for the upper-limb after stroke.

Motor learning in neurological rehabilitation

While most upper limb training interventions in neurological rehabilitation are based on established principles of motor learning and neural plasticity, recovery potential may be improved if the focus includes remediating an individual's specific motor impairment within the framework of a motor control theory. This paper reviews current theories of motor control and motor learning and describes how they can be incorporated into training programs to enhance sensorimotor recovery in patients with neurological lesions. An emphasis is placed on dynamical systems theory and the use of new technologies such as virtual, augmented and mixed reality applications for rehabilitation to facilitate learning.Implications for RehabilitationKinematic abundance allows the healthy nervous system to produce different combinations of joint rotations to perform a desired task.The structure of practice to improve the movement repertoire in rehabilitation should take into account the kinematic abundance of the system.Learning can be enhanced by varied practice with feedback about key movement elements.Virtual reality environments provide opportunities to manipulate the structure and schedule of practice and feedback.

Self-Directed Exergaming for Stroke Upper Limb Impairment Increases Exercise Dose Compared to Standard Care

Background. One of the strongest modifiable determinants of rehabilitation outcome is exercise dose. Technologies enabling self-directed exercise offer a pragmatic means to increase dose, but the extent to which they achieve this in unselected cohorts, under real-world constraints, is poorly understood. Objective. Here we quantify the exercise dose achieved by inpatient stroke survivors using an adapted upper limb (UL) exercise gaming (exergaming) device and compare this with conventional (supervised) therapy. Methods. Over 4 months, patients presenting with acute stroke and associated UL impairment were screened at a single stroke centre. Participants were trained in a single session and provided with the device for unsupervised use during their inpatient admission. Results. From 75 patients referred for inpatient UL therapy, we recruited 30 (40%), of whom 26 (35%) were able to use the device meaningfully with their affected UL. Over a median enrolment time of 8 days (IQR: 5–14), self-directed UL exercise duration using the device was 26 minutes per day (median; IQR: 16–31), in addition to 25 minutes daily conventional UL therapy (IQR: 12–34; same cohort plus standard care audit; joint n = 50); thereby doubling total exercise duration (51 minutes; IQR: 32–64) relative to standard care (Z = 4.0, P <.001). The device enabled 104 UL repetitions per day (IQR: 38–393), whereas conventional therapy achieved 15 UL repetitions per day (IQR: 11–23; Z = 4.3, P <.001). Conclusion. Self-directed adapted exergaming enabled participants in our stroke inpatient cohort to increase exercise duration 2-fold, and repetitions 8-fold, compared to standard care, without requiring additional professional supervision.

Effectiveness of Virtual Reality in the Rehabilitation of Motor Function of Patients With Subacute Stroke: A Meta-Analysis

Stroke is a major cause of death and disability in adults. Conventional therapy (CT) has limited effectiveness, and therefore, various virtual reality (VR) rehabilitation programs have been designed. However, their efficacy in regaining motor function in patients with subacute stroke is questionable. Therefore, we conducted this meta-analysis to determine the efficacy of VR, compared to CT, in restoring motor function in this patient population. Up to October 10, 2020, nine electronic databases were searched for relevant articles reporting the effectiveness of VR in regaining motor function in patients with subacute stroke. This search was updated on March 7, 2021, with no additional added articles. The control group included CT, physical therapy, occupational therapy, or a combination of them. Effectiveness is defined as the positive change from baseline values to the last follow-up point. The Cochrane's revised risk-of-bias tool was used to determine the quality of included trials. A metaregression analysis was conducted to determine the effect of "time since last stroke" on reported outcomes. Publication bias and sensitivity analyses were also carried out. A total of 19 studies (17 randomized controlled trials, 1 cohort study, and 1 crossover trial) were included in the qualitative analysis, whereas 16 trials were meta-analyzed. A great improvement in motor function was noted in the VR group, when compared to preintervention values [standardized mean difference (SMD) = 1.14; 95% confidence interval (CI) = 0.77-1.52; I ² = 82%; P < 0.001]. When compared to CT, VR resulted in mild improvement in motor function (SMD = 0.47; 95% CI = 0.22-0.72; I ² = 75%; P < 0.001). However, upon trim-and-fill adjustment, this finding was deemed insignificant (SMD = 0.08; 95% CI = -0.16 to 0.33; I ² = 82.6%; P < 0.001). Ten studies had low risk, five had some concerns, three had high risk, and one had a moderate risk of bias. VR programs can be used jointly with CT for the rehabilitation of the motor function of patients with subacute stroke. However, more studies are still warranted to determine the effectiveness of these interventions in retaining the cognitive function and physical performance of such patients.

Commercial gaming devices for stroke upper limb rehabilitation: The stroke survivor experience

Introduction

Approximately 30% of stroke survivors experience an upper limb impairment, which impacts on participation and quality of life. Gaming devices (Nintendo Wii) are being incorporated into rehabilitation to improve function. We explored the stroke survivor experience of gaming as an upper limb intervention.

Methods

Semi-structured, individual interviews with stroke survivors living within the UK were completed. Interviews were audio-recorded, transcribed verbatim and analysed using Framework methods. Transcripts were coded and summarised into thematic charts. Thematic charts were refined during analysis until the final framework emerged.

Results

We captured experiences of 12 stroke survivors who used Nintendo Wii. Gaming devices were found to be acceptable for all ages but varying levels of enthusiasm existed. Enthusiastic players described gaming as having a positive impact on their motivation to engage in rehabilitation. For some, this became a leisure activity, encouraging self-practice. Non-enthusiastic players preferred sports to gaming.

Conclusion

An in-depth account of stroke survivor experiences of gaming within upper limb rehabilitation has been captured. Suitability of gaming should be assessed individually and stroke survivor abilities and preference for interventions should be taken into consideration. There was no indication that older stroke survivors or those with no previous experience of gaming were less likely to enjoy the activity.

Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review

Virtual reality and active video games (VR/AVGs) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice. However, clinical adoption remains low despite a growing evidence base and the recent development of clinically accessible and rehabilitation-specific VR/AVG systems. Given clinicians' eagerness for resources to support VR/AVG use, a critical need exists for knowledge translation (KT) interventions to facilitate VR/AVG integration into clinical practice. KT interventions have the potential to support adoption by targeting known barriers to, and facilitators of, change. This scoping review of the VR/AVG literature uses the Theoretical Domains Framework (TDF) to (1) structure an overview of known barriers and facilitators to clinical uptake of VR/AVGs for rehabilitation; (2) identify KT strategies to target these factors to facilitate adoption; and (3) report the results of these strategies. Barriers/facilitators and evaluated or proposed KT interventions spanned all but 1 and 2 TDF domains, respectively. Most frequently cited barriers/facilitators were found in the TDF domains of Knowledge, Skills, Beliefs About Capabilities, Beliefs About Consequences, Intentions, Goals, Environmental Context and Resources, and Social Influences. Few studies empirically evaluated KT interventions to support adoption; measured change in VR/AVG use did not accompany improvements in self-reported skills, attitudes, and knowledge. Recommendations to target frequently identified barriers include technology development to meet end-user needs more effectively, competency development for end-users, and facilitated VR/AVG implementation in clinical settings. Subsequent research can address knowledge gaps in both clinical and VR/AVG implementation research, including on KT intervention effectiveness and unexamined TDF domain barriers. LEVEL OF EVIDENCE: IV.

Patient Engagement Is Related to Impairment Reduction During Digital Game-Based Therapy in Stroke

OBJECTIVE

Upper limb impairment in the chronic phase of stroke recovery is persistent, disabling, and difficult to treat. The objectives of this study were to determine whether therapeutic enjoyment is related to clinical improvement after upper limb rehabilitation and to assess the feasibility of a therapy gaming system.

MATERIALS AND METHODS

Ten chronic stroke survivors with persistent upper limb impairment were enrolled in the study. Upper limb impairment was evaluated by using the Fugl-Meyer Assessment of Upper Extremity Function (FMA-UE). The Physical Activity Enjoyment Scale (PACES) assessed the level of therapy enjoyment, and the System Usability Scale (SUS) measured the ease of operation of the game. Upper limb therapy involved 30 minutes of novel digital gaming therapy, three times per week, for 6 weeks.

RESULTS

The average improvement in the FMA-UE after the digital gaming therapy was 2.8 (±2.1) points. Participants scored the digital gaming system as having good usability (SUS: 72 ± 7.9), and the physical activity as enjoyable (PACES: 65.8 ± 10.6). There was a strong positive correlation between improvement in the FMA-UE score and the PACES (Spearman's Rho = 0.84; P < 0.002).

CONCLUSION

This pilot study demonstrates the feasibility and potential for improvements in upper limb motor function by using digital gaming in the chronic stroke patient population. The positive correlation found between therapy enjoyment and clinical gains highlights the importance of engagement in therapy to optimize outcomes in chronic stroke survivors.

The Present and Future of Robotic Technology in Rehabilitation

Robotic technology designed to assist rehabilitation can potentially increase the efficiency of and accessibility to therapy by assisting therapists to provide consistent training for extended periods of time, and collecting data to assess progress. Automatization of therapy may enable many patients to be treated simultaneously and possibly even remotely, in the comfort of their own homes, through telerehabilitation. The data collected can be used to objectively assess performance and document compliance as well as progress. All of these characteristics can make therapists more efficient in treating larger numbers of patients. Most importantly for the patient, it can increase access to therapy which is often in high demand and rationed severely in today's fiscal climate. In recent years, many consumer grade low-cost and off-the-shelf devices have been adopted for use in therapy sessions and methods for increasing motivation and engagement have been integrated with them. This review paper outlines the effort devoted to the development and integration of robotic technology for rehabilitation.

Democratizing Neurorehabilitation: How Accessible are Low-Cost Mobile-Gaming Technologies for Self-Rehabilitation of Arm Disability in Stroke?

Motor-training software on tablets or smartphones (Apps) offer a low-cost, widely-available solution to supplement arm physiotherapy after stroke. We assessed the proportions of hemiplegic stroke patients who, with their plegic hand, could meaningfully engage with mobile-gaming devices using a range of standard control-methods, as well as by using a novel wireless grip-controller, adapted for neurodisability. We screened all newly-diagnosed hemiplegic stroke patients presenting to a stroke centre over 6 months. Subjects were compared on their ability to control a tablet or smartphone cursor using: finger-swipe, tap, joystick, screen-tilt, and an adapted handgrip. Cursor control was graded as: no movement (0); less than full-range movement (1); full-range movement (2); directed movement (3). In total, we screened 345 patients, of which 87 satisfied recruitment criteria and completed testing. The commonest reason for exclusion was cognitive impairment. Using conventional controls, the proportion of patients able to direct cursor movement was 38–48%; and to move it full-range was 55–67% (controller comparison: p>0.1). By comparison, handgrip enabled directed control in 75%, and full-range movement in 93% (controller comparison: p<0.001). This difference between controllers was most apparent amongst severely-disabled subjects, with 0% achieving directed or full-range control with conventional controls, compared to 58% and 83% achieving these two levels of movement, respectively, with handgrip. In conclusion, hand, or arm, training Apps played on conventional mobile devices are likely to be accessible only to mildly-disabled stroke patients. Technological adaptations such as grip-control can enable more severely affected subjects to engage with self-training software.

Effect of information feedback on training standing up following stroke: a pilot feasibility study

BACKGROUND AND OBJECTIVE

The ability to stand up is reduced following stroke. Traditional biofeedback is effective in improving the performance of lower limb activities. The aim of this study was to investigate the feasibility of and potential for information feedback from a simple inexpensive device to improve the ability to stand up from a chair in people following stroke.

METHODS

A single-group study with pre-post measures design was used. Twenty people with hemiplegic stroke in inpatient rehabilitation received 10 sessions over 2 weeks of information feedback about foot placement during training of standing up. Progression involved increasing repetitions, increasing difficulty and fading feedback. Feasibility was determined by adherence, time taken, acceptability and safety. Clinical outcomes were the time taken to stand up, quality and foot position measured using the 5-Times-Sit-To-Stand-Test and carryover into daily activities measured by covert observation.

RESULTS

The study was feasible with 97% of sessions completed, taking 19 (SD 6) to 25 (SD 10) minutes. Participants understood (4.6/5), found useful (4.6/5), challenging (4.4/5) and would recommend (4.7/5) the training. The time to stand up 5 times decreased by 24 (95% CI -48 to -1) s, and the quality of standing improved by 1.0/10.0 (95% CI 0.2 to 1.8). Carryover of the correct foot placement occurred to real life, with the beginning foot position correct 2.1/3.0 (95% CI 1.6 to 2.6) and end foot position correct 1.8/3.0 (95% CI 1.2 to 2.4) occasions.

CONCLUSIONS

The training is feasible and has the potential to improve the ability to stand up.

Stroke Rehabilitation Using Virtual Environments

This review covers the rationale, mechanisms, and availability of commercially available virtual environment-based interventions for stroke rehabilitation. It describes interventions for motor, speech, cognitive, and sensory dysfunction. Also discussed are the important features and mechanisms that allow virtual environments to facilitate motor relearning. A common challenge is the inability to translate success in small trials to efficacy in larger populations. The heterogeneity of stroke pathophysiology has been blamed, and experts advocate for the study of multimodal approaches. Therefore, this article also introduces a framework to help define new therapy combinations that may be necessary to address stroke heterogeneity.