Gamifying Motor Rehabilitation Therapies: Challenges and Opportunities of Immersive Technologies

Design and validation of PACTUS: A gamified electronic device for stroke rehabilitation

BACKGROUND AND OBJECTIVE

Stroke remains a significant global concern, particularly as populations age and the incidence of stroke rises. Approximately one third of stroke survivors experience loss of autonomy, often leading to a decreased participation in rehabilitation due to economic, emotional, and social barriers. In response to these challenges, this study introduces PACTUS, an innovative gamified device designed for the rehabilitation of cognitive and motor functions in the upper limbs of patients with post-stroke. PACTUS aims to improve patient motivation and enable precise monitoring of rehabilitation progress by both therapists and patients.

METHODS

Developed in collaboration with the Institute of Neurosciences at the Red Cross Hospital in Cordoba, the device underwent a pilot pre-test phase with two neurological patients. An observational study was also conducted involving 30 volunteers, including healthy individuals and patients with various neurological disorders, to evaluate the safety, feasibility, acceptability, and potential utility of PACTUS in a broader clinical context.

RESULTS

Preliminary findings suggest that PACTUS is a promising tool for stroke rehabilitation, offering a safe and cost-effective method to ensure accurate upper limb movement.

CONCLUSIONS

Feedback from both patients and therapists highlighted areas of improvement and underscored the device's capacity to adapt to different rehabilitation stages, affirming its broad application potential across diverse neurological conditions.

Virtual reality exergames for enhancing engagement in stroke rehabilitation: A narrative review

This narrative review focuses on upper-limb stroke rehabilitation and virtual reality (VR) exergaming interventions that seek to facilitate the rehabilitation process. We examine exergaming interventions from the perspective of diegesis ("narration"), an aspect often overlooked despite its significance in neuronal rehabilitation. The importance of diegesis and narrative engagement in rehabilitation exergames started becoming clear only recently, with findings in the field of neurology underscoring the impact of purpose-driven task engagement on neuroplasticity. We begin this review by examining various frameworks for stroke rehabilitation exergames and identifying the gaps in the existing literature. We continue with summarizing the literature on exergames in upper-limb stroke rehabilitation, emphasizing the contribution of diegesis on exercise motivation and engagement. Finally, we conclude this review by offering insights into the current state of research, along with future perspectives on the topic.

Analysis of Gait Kinematics in Smart Walker-Assisted Locomotion in Immersive Virtual Reality Scenario

The decline in neuromusculoskeletal capabilities of older adults can affect motor control, independence, and locomotion. Because the elderly population is increasing worldwide, assisting independent mobility and improving rehabilitation therapies has become a priority. The combination of rehabilitation robotic devices and virtual reality (VR) tools can be used in gait training to improve clinical outcomes, motivation, and treatment adherence. Nevertheless, VR tools may be associated with cybersickness and changes in gait kinematics. This paper analyzes the gait parameters of fourteen elderly participants across three experimental tasks: free walking (FW), smart walker-assisted gait (AW), and smart walker-assisted gait combined with VR assistance (VRAW). The kinematic parameters of both lower limbs were captured by a 3D wearable motion capture system. This research aims at assessing the kinematic adaptations when using a smart walker and how the integration between this robotic device and the VR tool can influence such adaptations. Additionally, cybersickness symptoms were investigated using a questionnaire for virtual rehabilitation systems after the VRAW task. The experimental data indicate significant differences between FW and both AW and VRAW. Specifically, there was an overall reduction in sagittal motion of 16%, 25%, and 38% in the hip, knee, and ankle, respectively, for both AW and VRAW compared to FW. However, no significant differences between the AW and VRAW kinematic parameters and no adverse symptoms related to VR were identified. These results indicate that VR technology can be used in walker-assisted gait rehabilitation without compromising kinematic performance and presenting potential benefits related to motivation and treatment adherence.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Limitations and solutions of low cost virtual reality mirror therapy for post-stroke patients

Mirror therapy is applied to reduce phantom pain and as a rehabilitation technique in post-stroke patients. Using Virtual Reality and head-mounted displays this therapy can be performed in virtual scenarios. However, for its efficient use in clinical settings, some hardware limitations need to be solved. A new system to perform mirror therapy in virtual scenarios for post-stroke patients is proposed. The system requires the patient a standalone virtual reality headset with hand-tracking features and for the rehabilitator an external computer or tablet device. The system provides functionalities for the rehabilitator to prepare and follow-up rehabilitation sessions and a virtual scenario for the patient to perform rehabilitation. The system has been tested on a real scenario with the support of three experienced rehabilitators and considering ten post-stroke patients in individual sessions focused on upper limb motor rehabilitation. The development team observed all the sessions and took note of detected errors regarding technological aspects. Solutions to solve detected problems will be proposed and evaluated in terms of feasibility, performance cost, additional system cost, number of solved issues, new limitations, or advantages for the patient. Three types of errors were detected and solved. The first error is related to the position of the hands relative to the head-mounted display. To solve it the exercise area can be limited to avoid objectives that require turning the head too far. The second error is related to the interaction between the hands and the virtual objects. It can be solved making the main hand non-interactive. The last type of error is due to patient limitations and can be mitigated by having a virtual hand play out an example motion to bring the patient's attention back to the exercise. Other solutions have been evaluated positively and can be used in addition or instead of the selected ones. For mirror therapy based on virtual reality to be efficient in post-stroke rehabilitation the current head-mounted display-based solutions need to be complemented with specific strategies that avoid or mitigate the limitations of the technology and the patient. Solutions that help with the most common issues have been proposed.

Survey of Movement Reproduction in Immersive Virtual Rehabilitation

Virtual reality (VR) has emerged as a powerful tool for rehabilitation. Many effective VR applications have been developed to support motor rehabilitation of people affected by motor issues. Movement reproduction, which transfers users' movements from the physical world to the virtual environment, is commonly used in VR rehabilitation applications. Three major components are required for movement reproduction in VR: (1) movement input, (2) movement representation, and (3) movement modulation. Until now, movement reproduction in virtual rehabilitation has not yet been systematically studied. This article aims to provide a state-of-the-art review on this subject by focusing on existing literature on immersive motor rehabilitation using VR. In this review, we provided in-depth discussions on the rehabilitation goals and outcomes, technology issues behind virtual rehabilitation, and user experience regarding movement reproduction. Similarly, we present good practices and highlight challenges and opportunities that can form constructive suggestions for the design and development of fit-for-purpose VR rehabilitation applications and can help frame future research directions for this emerging area that combines VR and health.

Mixed Reality Platforms in Telehealth Delivery: Scoping Review

BACKGROUND

The distinctive features of the digital reality platforms, namely augmented reality (AR), virtual reality (VR), and mixed reality (MR) have extended to medical education, training, simulation, and patient care. Furthermore, this digital reality technology seamlessly merges with information and communication technology creating an enriched telehealth ecosystem. This review provides a composite overview of the prospects of telehealth delivered using the MR platform in clinical settings.

OBJECTIVE

This review identifies various clinical applications of high-fidelity digital display technology, namely AR, VR, and MR, delivered using telehealth capabilities. Next, the review focuses on the technical characteristics, hardware, and software technologies used in the composition of AR, VR, and MR in telehealth.

METHODS

We conducted a scoping review using the methodological framework and reporting design using the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) guidelines. Full-length articles in English were obtained from the Embase, PubMed, and Web of Science databases. The search protocol was based on the following keywords and Medical Subject Headings to obtain relevant results: "augmented reality," "virtual reality," "mixed-reality," "telemedicine," "telehealth," and "digital health." A predefined inclusion-exclusion criterion was developed in filtering the obtained results and the final selection of the articles, followed by data extraction and construction of the review.

RESULTS

We identified 4407 articles, of which 320 were eligible for full-text screening. A total of 134 full-text articles were included in the review. Telerehabilitation, telementoring, teleconsultation, telemonitoring, telepsychiatry, telesurgery, and telediagnosis were the segments of the telehealth division that explored the use of AR, VR, and MR platforms. Telerehabilitation using VR was the most commonly recurring segment in the included studies. AR and MR has been mainly used for telementoring and teleconsultation. The most important technical features of digital reality technology to emerge with telehealth were virtual environment, exergaming, 3D avatars, telepresence, anchoring annotations, and first-person viewpoint. Different arrangements of technology-3D modeling and viewing tools, communication and streaming platforms, file transfer and sharing platforms, sensors, high-fidelity displays, and controllers-formed the basis of most systems.

CONCLUSIONS

This review constitutes a recent overview of the evolving digital AR and VR in various clinical applications using the telehealth setup. This combination of telehealth with AR, VR, and MR allows for remote facilitation of clinical expertise and further development of home-based treatment. This review explores the rapidly growing suite of technologies available to users within the digital health sector and examines the opportunities and challenges they present.

Proposal of a Wearable Multimodal Sensing-Based Serious Games Approach for Hand Movement Training After Stroke

Stroke often leads to hand motor dysfunction, and effective rehabilitation requires keeping patients engaged and motivated. Among the existing automated rehabilitation approaches, data glove-based systems are not easy to wear for patients due to spasticity, and single sensor-based approaches generally provided prohibitively limited information. We thus propose a wearable multimodal serious games approach for hand movement training after stroke. A force myography (FMG), electromyography (EMG), and inertial measurement unit (IMU)-based multi-sensor fusion model was proposed for hand movement classification, which was worn on the user’s affected arm. Two movement recognition-based serious games were developed for hand movement and cognition training. Ten stroke patients with mild to moderate motor impairments (Brunnstrom Stage for Hand II-VI) performed experiments while playing interactive serious games requiring 12 activities-of-daily-living (ADLs) hand movements taken from the Fugl Meyer Assessment. Feasibility was evaluated by movement classification accuracy and qualitative patient questionnaires. The offline classification accuracy using combined FMG-EMG-IMU was 81.0% for the 12 movements, which was significantly higher than any single sensing modality; only EMG, only FMG, and only IMU were 69.6, 63.2, and 47.8%, respectively. Patients reported that they were more enthusiastic about hand movement training while playing the serious games as compared to conventional methods and strongly agreed that they subjectively felt that the proposed training could be beneficial for improving upper limb motor function. These results showed that multimodal-sensor fusion improved hand gesture classification accuracy for stroke patients and demonstrated the potential of this proposed approach to be used as upper limb movement training after stroke.

The Application of Technological Intervention for Stroke Rehabilitation in Southeast Asia: A Scoping Review With Stakeholders' Consultation

BACKGROUND

The technological intervention is considered as an adjunct to the conventional therapies applied in the rehabilitation session. In most high-income countries, technology has been widely used in assisting stroke survivors to undergo their treatments. However, technology use is still lacking in Southeast Asia, especially in middle- and low-income countries. This scoping review identifies and summarizes the technologies and related gaps available in Southeast Asia pertaining to stroke rehabilitation.

METHODS

The JBI manual for evidence synthesis was used to conduct a scoping study. Until September 2021, an electronic search was performed using four databases (Medline, CINAHL, Scopus, ASEAN Citation Index). Only the studies that were carried out in Southeast Asia were chosen.

RESULTS

Forty-one articles were chosen in the final review from 6,873 articles found during the initial search. Most of the studies reported the implementation of technological intervention combined with conventional therapies in stroke rehabilitation. Advanced and simple technologies were found such as robotics, virtual reality, telerehabilitation, motion capture, assistive devices, and mobility training from Singapore, Thailand, Malaysia, and Indonesia. The majority of the studies show that technological interventions can enhance the recovery period of stroke survivors. The consultation session suggested that the technological interventions should facilitate the needs of the survivors, caregivers, and practitioners during the rehabilitation.

CONCLUSIONS

The integration of technology into conventional therapies has shown a positive outcome and show significant improvement during stroke recovery. Future studies are recommended to investigate the potential of home-based technological intervention and lower extremities.

Promotion of active ageing through interactive artificial agents in a smart environment

Abstract

Societies in the most developed countries have witnessed a significant ageing of the population in recent decades, which increases the demand for healthcare services and caregivers. The development of technologies to help the elderly, so that they can remain active and independent for a longer time, helps to mitigate the sustainability problem posed in care services. This article follows this new trend, proposing a multi-agent system composed of a smart camera network, centralised planning agent, a virtual coach, and robotic exercise buddy, designed to promote regular physical activity habits among the elderly. The proposed system not only persuades the users to perform exercise routines, but also guides and accompanies them during exercises in order to provide effective training and engagement to the user. The different agents are combined in the system to exploit their complementary features in the quest for an effective and engaging training system. Three variants of the system, involving either a partial set of those agents or the full proposed system, were evaluated and compared through a pilot study conducted with 12 elderly users. The results demonstrate that all variants are able to guide the user in an exercise routine, but the most complete system that includes a robotic exercise buddy was the best scored by the participants.

Article Highlights

IoT Based Virtual Reality Game for Physio-therapeutic Patients

Biofeedback therapy trains the patient to control voluntarily the involuntary process of their body. This non-invasive and non-drug treatment is also used as a means to rehabilitate the physical impairments that may follow a stroke, a traumatic brain injury or even in neurological aspects within occupational therapy. The idea behind this study is based on using immersive gaming as a tool for physical rehabilitation that combines the idea of biofeedback and physical computing to get a patient emotionally involved in a game that requires them to do the exercises in order to interact with the game. This game is aimed towards addressing the basic treatment for ‘Frozen Shoulder’. In this work, the physical motions are captured by the wearable ultrasonic sensor attached temporarily to the various limbs of the patient. The data received from the sensors are then sent to the game via serial wireless communication. There are two main aspects to this study: motion capturing and game design. The current status of the application is a single ultrasonic detector. The experimental result shows that physio-therapeutic patients are benefited through the IoT based virtual reality game.

Immersive Environment for Occupational Therapy: Pilot Study

There has been increasing interest in the application of virtual reality (VR) to occupational therapy and rehabilitation fields. This work presents a VR-based city adventure framework designed for occupational therapy. Its concept is based on taking the user to travel around a virtual city, where the motion is powered by the execution of some type of physical exercise, namely cycling in the current example. This framework is extensible and may integrate different goals focused on improving/maintaining motor and cognitive skills necessary for daily activities, mainly through upper and lower limb exercises and mental challenges. This led to the development of an immersive system, which was tested with an elderly sample (15 participants) in a day center and at a retirement home. Usability, satisfaction, performance and side effects were evaluated to understand future applicability and work directions.