[ARTICLE] Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation – Full Text HTML/PDF



The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming.


We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire.


In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p < .001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p = .074), significantly shorter travel distance (p < .001), higher movement efficiency (p < .001) and higher performance scores (p < .001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance.


Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation.


Dealing with the social and economical burden resulting from the high number of stroke survivors with permanent disability represents a major challenge for modern societies. The challenge becomes yet higher taking into account the enduring aging of the population worldwide [1] that will consequently result in the increase of the number of individuals with age related diseases such as stroke. For the particular case of the USA, estimates indicate that by 2030, ~4 % of the population will have experienced a stroke, with related costs expected to rise from $71.55 billion to $183.13 billion between 2012 and 2030 [2]. New strategies have to be found to face this upcoming scenario, otherwise it will represent a large burden on healthcare systems and caregivers.

One approach relies on home-based rehabilitation, so that stroke survivors can continue their rehabilitation program after hospital discharge with minimal supervision. Home-based stroke rehabilitation has been increasingly addressed during the last years, and while showing promising results in terms of feasibility and impact on recovery [3, 4] it also poses a number of technical and human challenges. In the concrete case of computer-based rehabilitation, current technology allows offering training scenarios adjusted to the characteristics of users, with detailed progress reports and remote monitorization. Moreover, one of the main advantages relies on the fact that most of these applications have protocols that promote hundreds of task-specific movement repetitions. There is evidence that the conjunction of these two factors, increased number of repetitions and task-specificity, is an important ingredient to achieve reorganization of cortical maps after stroke [5, 6]. Here, technology based solutions can play an important role to increase functional movement practice and impact recovery. There are however challenges when deploying such technologies in the home. One challenge relates to the definition of rehabilitation approaches that are adequate for a home environment. What is the most effective strategy to support users when they have to use these systems on their own or with minimum supervision? Self-managed computerized rehabilitation should be straightforward to use, tailor exercises to the profile of users, address function, set goals, improve self-efficacy, provide instantaneous feedback on performance and be engaging [79]. A second challenge in home-based approaches in general is long-term treatment adherence. It has been observed that compliance tends to decrease over time below recommended levels for reasons such as insufficient familiarity with technology, competing commitments, or simply lack of motivation [1012]. Hence, it is important to investigate what characteristics should be included in such systems so that stroke survivors feel more engaged and motivated to use these tools in a systematic way over long periods of time.

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