People with neurological injuries such as stroke should exercise frequently and intensely to regain their motor abilities, but are generally hindered by lack of motivation. One way to increase motivation in rehabilitation is through competitive exercises, but such exercises have only been tested in single brief sessions and usually did not adapt difficulty to the patient’s abilities.
We designed a competitive arm rehabilitation game for two players that dynamically adapts its difficulty to both players’ abilities. This game was evaluated by two participant groups: 15 participants with chronic arm impairment who exercised at home with an unimpaired friend or relative, and 20 participants in the acute or subacute phase of stroke who exercised in pairs (10 pairs) at a rehabilitation clinic. All participants first played the game against their human opponent for 3 sessions, then played alone (against a computer opponent) in the final, fourth session. In all sessions, participants’ subjective experiences were assessed with the Intrinsic Motivation Inventory questionnaire while exercise intensity was measured using inertial sensors built into the rehabilitation device. After the fourth session, a final brief questionnaire was used to compare competition and exercising alone.
Participants who played against an unimpaired friend or relative at home tended to prefer competition (only 1 preferred exercising alone), and exhibited higher enjoyment and exercise intensity when competing (first three sessions) than when exercising alone (last session).
Participants who played against each other in the clinic, however, did not exhibit significant differences between competition and exercising alone. For both groups, there was no difference in enjoyment or exercise intensity between the first three sessions, indicating no negative effects of habituation or novelty.
Competitive exercises have high potential for unsupervised home rehabilitation, as they improve enjoyment and exercise intensity compared to exercising alone. Such exercises could thus improve rehabilitation outcome, but this needs to be tested in long-term clinical trials. It is not clear why participants who competed against each other at the clinic did not exhibit any advantages of competition, and further studies are needed to determine how different factors (environment, nature of opponent etc.) influence patients’ experiences with competitive exercises.
The study is not a clinical trial. While human subjects are involved, they do not participate in a full rehabilitation intervention, and no health outcomes are examined.
Electronic supplementary material
The online version of this article (10.1186/s12984-017-0336-9) contains supplementary material, which is available to authorized users.
Stroke is a leading cause of disability, with 795,000 new or recurrent strokes per year in the United States alone . 88% of survivors experience motor function impairment and thus require rehabilitation to regain their movement abilities . However, even top hospitals devote only an hour per day to motor rehabilitation , and exercise intensity is usually too low for optimal rehabilitation outcome . Patients are thus expected to exercise independently at home after leaving the clinic to fully regain their abilities, but frequently do not exercise frequently or intensely enough. For example, one study found that only 30% of unsupervised patients comply with prescribed home rehabilitation regimens . Another home rehabilitation study found that patients average around 1.5 h of exercise per week , while clinical studies involve at least 3 h of exercise per week [7, 8]. To improve home rehabilitation, it is therefore critical to increase the frequency and intensity of exercise.
One key reason for poor compliance in home rehabilitation is lack of motivation, which is an important predictor of rehabilitation outcome [9, 10]. While the definition of motivation in rehabilitation is blurry, it is generally agreed to involve a willingness to actively engage in exercise [11, 12]. To improve engagement, researchers have thus developed numerous rehabilitation games that try to both ensure high enjoyment (using, e.g., meaningful goals, in-game rewards and entertaining graphics [12–15]) and provide an appropriate exercise intensity via automated difficulty adaptation [12, 14, 16]. The games are controlled using motion tracking hardware such as the Microsoft Kinect or even with rehabilitation robots that provide limb support in addition to motion tracking. However, recent reviews have emphasized that such games are not yet sufficiently engaging for all patients [17, 18]. Therefore, additional rehabilitation game development and validation is necessary to improve patient engagement.[…]