Abstract
Background
After a stroke, experts recommend regular monitoring and kinematic assessments of patients to objectively measure motor recovery. With the rise of new technologies and increasing needs for neurorehabilitation, an interest in virtual reality has emerged. In this context, we have developed an immersive virtual reality version of the Box and Block Test (BBT-VR). The aim of this study was to assess the concurrent validity of the BBT-VR among patients with stroke and healthy participants.
Methods
Twenty-three healthy participants and 22 patients with stroke were asked to perform the classical Box and Block Test (BBT) and BBT-VR three times with both hands. Concurrent validity was assessed through correlations between these two tests and reliability of the BBT-VR through correlation on test–retest. Usability of the BBT-VR was also evaluated with the System Usability Scale. Hand kinematic data extracted from controller’s 3D position allowed to compute mean velocity (Vmean), peak velocity (Vpeak) and smoothness (SPARC).
Results
Results showed strong correlations between the number of blocks displaced with the BBT and the BBT-VR among patients with stroke for affected (r = 0.89; p < 0.001) and less-affected hands (r = 0.76; p < 0.001) and healthy participants for dominant (r = 0.58; p < 0.01) and non-dominant hands (r = 0.68; p < 0.001). Reliability for test–retest was excellent (ICC > 0.8; p < 0.001) and usability almost excellent (System Usability Scale = 79 ± 12.34%). On average participants moved between 30 and 40% less blocks during the BBT-VR than during the BBT. Healthy participants demonstrated significantly higher kinematic measures (Vmean = 0.22 ± 0.086 ms−1; Vpeak = 0.96 ± 0.341 ms−1; SPARC = − 3.31 ± 0.862) than patients with stroke (Vmean = 0.12 ± 0.052 ms−1; Vpeak = 0.60 ± 0.202 ms−1; SPARC = − 5.04[− 7.050 to − 3.682]).
Conclusion
The BBT-VR is a usable, valid and reliable test to assess manual dexterity, providing kinematic parameters, in a population of patients with stroke and healthy participants.
Trial registration http://www.clinicaltrials.gov; Unique identifier: NCT04694833, Date of registration: 11/24/2020
Background
After a stroke, almost 80% of patients present with upper-limb impairments such as hemiparesis and sensory deficits [1]. These dysfunctions may be responsible for impaired manual dexterity which leads to activity limitation and participation restriction [2]. Most patients will progressively recover from these deficits, typically reaching a plateau of recovery after 6 months to one year of rehabilitation [3]. In clinical routine and research, it is recommended to frequently evaluate patients at different time points in order to establish prognostics and plan rehabilitation projects. In this context, experts recommend regular monitoring and assessment using validated measures [4]. Experts also recommend implementing kinematic analysis in the evaluation of patients to objectively measure recovery [5].
The Box and Block Test (BBT) is one of the most used and recommended tools to evaluate unilateral manual dexterity [6, 7]. The BBT comprises a box divided into two compartments by a wooden separation and 150 small wood cubic blocks (1-inch). The BBT consists of displacing a maximum number of small blocks, one-by-one, from the compartment located on the tested side to the other using the same hand (taking care to pass over the separation). The score is obtained by counting the number of blocks correctly displaced within 60 s. The BBT has shown good inter/intra-examinator reliability properties and has been validated in healthy participants and adults with stroke [7,8,9,10,11,12].
With the rise of stroke incidence, there are increasing needs for neurorehabilitation and for research to new effective treatments methods using immersive and non-immersive virtual reality (VR). VR provides an effective rehabilitation approach that offers the possibility to deliver goal-oriented tasks, multisensorial and performance feedback, and increased treatment intensity [13,14,15,16]. Several studies also suggested that VR could improve patients’ adherence by increasing motivation [17, 18]. The addition of playful interventions such as those provided by serious games may be an effective approach to increase adherence in patients with stroke [19]. Moreover, when provided with an autonomous headset, VR offers patients the possibility to rehabilitate alone and at home. Most VR systems can track hand movements using integrated infrared camera systems or using inertial measurements units present in the controllers. However, despite its potential, the use of immersive VR to perform functional assessments and to analyse upper limb kinematics has been so far under explored for post-stroke rehabilitation [20].
The interest of developing such virtual tests is multiple. It may help clinicians to objectively measure patient’s performance using the automatic computation of quantitative measures and therefore reduce inter-rater subjectivity present in the classical evaluation. It may also be part of a complete home-based virtual rehabilitation system where patients could self-rehabilitate through virtual serious games on one side, and, on the other, assess their cognitive and motor improvements using validated virtual evaluations. To respond to these needs and to the growing interest in telemedicine, we developed a non-commercial immersive virtual version of the BBT (BBT-VR).
In the literature, there are only three studies that have developed a virtual BBT. One study used a non-immersive VR device involving a depth-sensing camera [21]. Results showed good correlations between the BBT and the non-immersive BBT among patients with stroke. However, non-immersive VR does not enable tactile and realistic 3D visual feedback of participant’s hand position, reducing the user experience of the patient. Another published paper developed a virtual BBT using an immersive headset with hand tracking technology (Leap Motion Controller—Ultraleap) to assess unilateral manual dexterity. The study evaluated the concurrent validity of the virtual BBT among patients with Parkinson Disease [22] and results indicated moderate correlation between the virtual BBT and BBT scores. The third paper developed a virtual BBT using an immersive headset with hand-tracking technology [23]. Validity was not assessed, but results showed that healthy participants, on average, displaced 35 more blocks in the BBT than in the virtual BBT. In all three of these studies, the virtual BBT systems required the use of a powerful expensive computer making the tests less portable, and they did not enable tactile feedback for block interaction, which reduces the user experience. In addition, none of these studies provided kinematic measures.
This study here aimed to develop an immersive virtual version of the BBT (BBT-VR) and assess concurrent validity among patients with stroke and healthy participants. The hypothesis was that the BBT-VR and BBT scores obtained by participants would be correlated. Secondary objectives were to assess the short-term test–retest reliability and usability of the BBT-VR test, and to compute and compare hand kinematics analyses. […]
TBI Rehabilitation 