[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF

Abstract

Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.

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[Abstract] Evaluation of custom-made VR exergame for at-home Stroke rehabilitation. A longitudinal single-arm study. – Full Text PDF

Abstract

Exercise games (Exergames) based on Virtual Reality (VR) have emerged as a promising option for supporting physical rehabilitation in stroke users. As a com- plementary therapy, they offer valuable benefits such as therapy engagement and enjoyment. In this study, we assessed the effectiveness of an immersive, custom- made VR exergame designed for upper limb rehabilitation in stroke participants aged 50 and above. We conducted 14 sessions of 15 minutes involving ten par- ticipants (6 females, ages 58.1 ± 7.5 years old) who volunteered to participate in an assisted at-home rehabilitation process. The study employed a range of evaluation tests to measure physical rehabilitation and game user experience out- comes. The tests included pre- and post-assessments of range of motion (ROM), the Ashworth spasticity test, and the Borg rating of perceived fatigue question- naire. To evaluate the game participant experience, we used the VR Neuroscience Questionnaire (VRNQ), and the Immersive Tendencies Questionnaire (ITQ). Our results revealed significant improvements in the range of motion for elbow and shoulder flexion, extension, adduction, and abduction. Furthermore, we observed a reduction in Ashworth spasticity, and the fatigue scale showed reduced per- ception comparing the last with the first session, although the difference was insignificant. The VRNQ questionnaire indicated significant enhancements in the domains related to ”Game Experience” and ”Game Mechanics” and an overall reduction of the perceived “Motion Sickness”. In the ITQ questionnaire, partic- ipants reported high levels of ”Attention,” and while there were no significant differences in ”Immersion” and ”Enjoyment,” a considerable improvement was observed in ”Excitement”. In summary, our results indicate that the immersive VR exergame improved the range of motion, spasticity, and overall game user experience among participants with stroke in a longitudinal, single-arm inter- vention. We conclude that using custom-made VR exergames is an effective and motivating tool for upper limb rehabilitation, with positive changes in both clin- ical and perception outcomes, and the positive and measurable effects persist after the first sessions. These findings support using VR exergames as a comple- mentary tool for at-home rehabilitation therapy with good ease of use, improved physical rehabilitation outcomes, and high treatment adherence.

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[Abstract] Exergames as a rehabilitation tool to enhance the upper limbs functionality and performance in chronic stroke survivors: a preliminary study

Post-stroke hemiplegia commonly occurs in stroke survivors, negatively impacting the quality of life. Despite the benefits of initial specific post-acute treatments at the hospitals, motor functions and physical mobility need to be constantly stimulated to avoid regression and subsequent hospitalizations for further rehabilitation treatments. This preliminary study proposes using gamified tasks in a virtual environment to stimulate and maintain upper limb mobility through a single RGB-D camera-based vision system (using Microsoft Azure Kinect DK). This solution is suitable for easy deployment and use in home environments. A cohort of 10 post-stroke subjects attended a 2-week gaming protocol consisting of Lateral Weightlifting (LWL) and Frontal Weightlifting (FWL) gamified tasks and gait as the instrumental evaluation task. Despite its short duration, there were statistically significant results (p < 0.05) between the baseline (T0) and the end of the protocol (TF) for Berg Balance Scale and Time Up-and-Go (9.8% and -12.3%, respectively). LWL and FWL showed significant results for unilateral executions: rate in FWL had an overall improvement of 38.5% (p < 0.001) and 34.9% (p < 0.01) for the paretic and non-paretic arm, respectively; similarly, rate in LWL improved by 19.9% (p < 0.05) for the paretic arm and 29.9% (p < 0.01) for non-paretic arm. Instead, bilateral executions had significant results for rate and speed: considering FWL, there was an improvement in rate with p < 0.01 (31.7% for paretic arm and 37.4% for non-paretic arm), whereas speed improved by 31.2% (p < 0.05) and 41.7% (p < 0.001) for the paretic and non-paretic arm, respectively; likewise, LWL showed improvement in rate with p < 0.001 (29.% for paretic arm and 27.8% for non-paretic arm) and in speed with 23.6% (p < 0.05) and 23.5% (p < 0.01) for the paretic and non-paretic arms, respectively. No significant results were recorded for gait task, although an overall good improvement was detected for arm swing asymmetry (-22.6%). Hence, this study suggests the potential benefits of continuous stimulation of upper limb function through gamified exercises and performance monitoring over medium-long periods in the home environment, thus facilitating the patient’s general mobility in daily activities.

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[ARTICLE] Rehabilitation via HOMe-Based gaming exercise for the Upper limb post Stroke (RHOMBUS): a qualitative analysis of participants’ experience – Full Text

Abstract

Objective To report participants’ experiences of trial processes and use of the Neurofenix platform for home-based rehabilitation following stroke. The platform, consisting of the NeuroBall device and Neurofenix app, is a non-immersive virtual reality tool to facilitate upper limb rehabilitation following stroke. The platform has recently been evaluated and demonstrated to be safe and effective through a non-randomised feasibility trial (RHOMBUS).

Design Qualitative approach using semistructured interviews. Interviews were audio recorded, transcribed verbatim and analysed using the framework method.

Setting Participants’ homes, South-East England.

Participants Purposeful sample of 18 adults (≥18 years), minimum 12 weeks following stroke, not receiving upper limb rehabilitation prior to the RHOMBUS trial, scoring 9–25 on the Motricity Index (elbow and shoulder), with sufficient cognitive and communicative abilities to participate.

Results Five themes were developed which explored both trial processes and experiences of using the platform. Factors that influenced participant’s decision to take part in the trial, their perceptions of support provided during the trial and communication with the research team were found to be important contextual factors effecting participants’ overall experience. Specific themes around usability and comfort of the NeuroBall device, factors motivating persistence and perceived effectiveness of the intervention were highlighted as being central to the usability and acceptability of the platform.

Conclusion This study demonstrated the overall acceptability of the platform and identified areas for enhancement which have since been implemented by Neurofenix. The findings add to the developing literature on the interface between virtual reality systems and user experience.

Introduction

Despite advancements in prevention, treatment and rehabilitation, stroke remains a leading cause of disability worldwide1 including in the UK where an estimated 77% of first-ever stroke survivors present with upper limb weakness.2 Less than 20% of stroke survivors regain full function of the upper limb at 6 months.3

A combination of poor upper limb recovery and evidence that conventional rehabilitation results in insufficient upper limb training4–6 has resulted in an increasing interest in alternative training programmes. Novel approaches include virtual reality (VR) platforms to intensify upper limb training,7–9 while providing motivational feedback to encourage engagement and the required repetition to drive recovery.10 11 Studies have demonstrated VR devices can encourage higher numbers of repetitions, provide immediate feedback on performance and stimulate the visual, auditory and tactile senses to increase neuroplasticity, therefore contributing to improvements in motor function and performance of daily activities.12 13 Within qualitative work in the field a common theme that has emerged between studies is the beneficial effect VR has on motivation and engagement with upper limb rehabilitation.14 15 Initial evidence suggests such platforms are safe and effective at improving impairment, activity and participation, with the current Cochrane Review stating that VR may be beneficial for the upper limb when used as an adjunct to usual care; however, the evidence is currently considered to be of low quality.7 16–20 A recent meta-analysis, which compared VR interventions that included gaming components with those which just provided visual feedback, found that the inclusion of gaming components produced larger treatment gains.21

Despite encouraging outcomes, platforms used to date are often inaccessible to stroke survivors due to cost and the physical demands of the user interface.11 22–27 A recent systematic review of the acceptability of these platforms indicated several desirable features such as usability, small size, ease of set-up, sufficient support and engagement through variability, challenge and performance-based feedback.28

The Neurofenix platform (www.neurofenix.com) is a non-immersive VR therapy platform for gamification of poststroke upper limb rehabilitation using the NeuroBall, a novel hand-controlled gaming device. Developed by stroke survivors, physiotherapists and bioengineers, it delivers a safe, upper limb training programme, which has demonstrated positive effects on upper limb impairment and function.29 However, for any platform to be integrated as part of standard care it must also be accessible and acceptable to the end users. This study aimed to explore the acceptability of using the VR platform for home-based upper limb rehabilitation within the context of a wider safety and feasibility trial with individuals in the chronic phase following stroke.30 […]

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[ARTICLE] Design recommendations for XR-based motor rehabilitation exergames at home – Full Text

Introduction: Acquired brain injuries pose significant societal and individual challenges worldwide. The adoption of XR technologies presents an opportunity to enhance current rehabilitation procedures. However, a comprehensive understanding of the specific requirements of different user groups in XR-based rehabilitation remains incomplete. Our objective was to identify design recommendations for designers and researchers of XR-based exergames for motor rehabilitation for lower-limb motor recovery at home.

Methods: After initially conducting a mini-literature review and brief market analysis, we used a human-centered design process, interviewing central stakeholders to understand their perspectives and using thematic analysis to identify recurring themes and insights related to XR-based rehabilitation.

Results: The resulting eight key themes for integrating XR-based exergames into acquired brain injuries (ABI) rehabilitation were safety, flexibility, efficacy, usability, technology, motivation, ownership, and social factors.

Conclusion: By addressing technical and user-oriented demands, our resulting design recommendations aid designers in developing meaningful XR-based rehabilitation exercises.

Introduction

Rapid developments in entertainment technologies have made immersive gaming based on extended reality (XR) increasingly accessible and enjoyable for the general public. However, these technologies also present huge opportunities for other domains, such as medical rehabilitation. In the field of rehabilitation, an increasing number of people suffer from acute brain injuries, which pose individual and societal challenges associated with support and treatment. Consequently, there is a strong demand for novel technological solutions. Integrating the widely available XR-based technologies in rehabilitation processes has the potential to facilitate and promote it. However, the individual requirements on XR-based technologies of all involved user groups still need to be better understood and, therefore, need closer examination. Thus, this article explores those individual requirements for developing user-centric XR-exergames in motor rehabilitation.

Injuries to the brain can result in various long-lasting disabilities due to the organ’s complexity. Those disabilities range from indiscernible symptoms, as the brain can compensate for some damage, to a combination of movement, sensory, emotional, and cognitive disabilities (Castor and El Massioui, 2018). Consequently, individuals affected by brain injuries often face significant difficulties performing daily activities independently and may experience social isolation (Demakis, 2007).

Acquired brain injuries (ABIs), including strokes and traumatic brain injuries (TBIs), are prevalent conditions, with a combined 81 million cases occurring each year (Dewan et al., 2018; Lindsay et al., 2019). Besides the individual tragedy ABIs cause, the economic burden on society for TBIs alone is estimated to be US$ 400 billion (as of 2017) globally (Maas et al., 2017), underlining the importance of more cost-effective rehabilitation procedures in the future.

Although stroke and TBIs differ in pathology and population, they share similarities regarding the resulting neurologic disorders and the subsequent rehabilitation procedure. Mainly the injury’s size, location, and severity are determinants of the experienced disabilities (Castor and El Massioui, 2018).

In summary, ABIs are a common and complex pathology with grave consequences for a single individual and a considerable socio-economic impact. Thus, the therapy process for ABI patients to restore lost functionality and reintegrate them into society is of high priority. However, this process is complicated due to the inherent complexity and pathology of the brain.

Central to the therapy of ABIs is the brain’s inherent capability to adapt and reorganize to compensate for some structural damages and regain lost functions. This process is also known as neuroplasticity. In the best case, neuroplastic processes can lead to a spontaneous recovery after an injury (Hatem et al., 2016). Nevertheless, this process requires external assistance and guidance to rehabilitate from related disabilities sufficiently. In traditional rehabilitation, the direct interaction between therapist and patient is indispensable throughout all rehabilitation phases. Despite its importance, this approach becomes economically impracticable with growing patient numbers and a decreasing healthcare workforce. Consequently, there is an ongoing effort to develop novel technologies to relieve therapists and improve the rehabilitation process. However, most research in motor rehabilitation focuses on improving upper limb functionality, and younger age groups with unique needs, capabilities, and interests are often overlooked (Rudberg et al., 2020; Holloway et al., 2022).

Only a few days after receiving ABI, the patient usually starts with intensive rehabilitation at a hospital or other medical facilities for several weeks. The patient is cared for there by a multidisciplinary team of medical professionals (Turner-Stokes, Sykes, and Silber, 2008). Physiotherapists and occupational therapists play a crucial role in the rehabilitation of motor and sensory impairments. Physiotherapists treat fundamental disabilities of movement, balance, and coordination, whereas occupational therapists assist in relearning higher-level task-specific functions (Govender and Kalra, 2007; Studer, 2007).

After regaining basic abilities, the patient is moved to outpatient units to provide regular supervised therapy while living at home. The training is transferred to the patient’s home, where the patients themself are responsible for following the advised training regime (Cullen et al., 2007; Young and Forster, 2007; Maas et al., 2017). The recovery often stagnates during the later stages of the rehabilitation process (sequela stage). Additionally, the training intensity usually decreases as prolonged, frequent supervised training is not economically viable. Besides the absence of motivational support, the patient receives less corrective feedback in this phase, leading to maladaptive neuroplastic changes and potentially reversing previous improvements (Maas et al., 2017).

Exergames in physical rehabilitation are a type of serious game that aims to facilitate motor rehabilitation through physical play, other than pure entertainment. Over the last few years, they have become a valuable tool for rehabilitation, as the automatization of the training relieves healthcare providers and facilitates home rehabilitation. Those games can guide a training exercise for motor rehabilitation and sometimes give feedback on execution quality (Rüth et al., 2023). To do so, the game input must reliably track the patients’ movements and consider the user’s specific needs and goals. Standard tracking devices are camera systems, balance boards (e.g., Wii fit), and accelerometers (e.g., VR headset and controller) (Gómez-Portes et al., 2021; Rüth et al., 2023).

Ongoing research investigates various technologies that can supplement or improve the current rehabilitation process. Especially promising are extended reality (XR) systems, such as virtual reality (VR), augmented reality (AR), and mixed reality (MR), due to their improved usability, accessibility, and ubiquitousness over the last few years. With the help of a head-mounted device (HMD), the users of such systems can run various applications that allow for the experience of a fully immersive virtual world environment. Sensors integrated into the HMD track the user’s head movement and can be supplemented with additional controllers, body trackers, headphones, or other feedback devices (Mathew and Pillai, 2020).

In this study, we aimed to discover how XR-based exergames can be employed for motor rehabilitation and how this can be sustainably incorporated into the rehabilitation ecosystem. This was done using human-centered design (HCD) approaches and methods to uncover the target user’s needs and requirements associated with motor rehabilitation using co-creation. Besides incorporating current research findings on XR-based exergaming for motor rehabilitation and commercial solutions, we interviewed stakeholders, such as subject matter experts, healthcare professionals, and patients. Based on the various knowledge streams, we developed design recommendations that can assist Human-Computer Interaction designers in understanding the respective stakeholders’ needs and in developing future XR-based lower limb rehabilitation applications with a particular focus on in-home treatment.

The article is organized as follows: First, we summarize the results of a brief review of the current state-of-the-art XR-based rehabilitation technology. Next, we present findings and resulting themes from interviews with subject matter experts, therapists, and ABI patients. These findings are presented as a general patient journey and exemplified through a specific patient scenario. We then discuss our findings and present design recommendations before concluding the article. […]

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FIGURE 1. Illustration of the described patient scenario and relevant milestones during the patient’s recovery. Created by Marianne Paulsen; reproduced with permission.

[Abstract + References] Design of Virtual Reality Exergames for Upper Limb Stroke Rehabilitation Following Iterative Design Methods: Usability Study

Abstract

Background Since the early 2000s, there has been a growing interest in using exercise video games (exergames) and virtual reality (VR)–based interventions as innovative methods to enhance physical rehabilitation for individuals with multiple disabilities. Over the past decade, researchers and exercise professionals have focused on developing specialized immersive exercise video games for various populations, including those who have experienced a stroke, revealing tangible benefits for upper limb rehabilitation. However, it is necessary to develop highly engaging, personalized games that can facilitate the creation of experiences aligned with the preferences, motivations, and challenges communicated by people who have had an episode of stroke. Objective This study seeks to explore the customization potential of an exergame for individuals who have undergone a stroke, concurrently evaluating its usability as a technological tool in the realm of physical therapy and rehabilitation. Methods We introduce a playtest methodology to enhance the design of a VR exergame developed using a user-centered approach for upper limb rehabilitation in stroke survivors. Over 4 playtesting sessions, stroke survivors interacted with initial game versions using VR headsets, providing essential feedback for refining game content and mechanics. Additionally, a pilot study involving 10 stroke survivors collected data through VR-related questionnaires to assess game design aspects such as mechanics, assistance, experience, motion sickness, and immersion. Results The playtest methodology was beneficial for improving the exergame to align with user needs, consistently incorporating their perspectives and achieving noteworthy results. The pilot study revealed that users had a positive response. In the first scenario, a carpenter presents a game based on the flexion-extension movement of the elbow; the second scenario includes a tejo game (a traditional Colombian throwing game) designed around game mechanics related to the flexion-extension movement of the shoulder; and in the third scenario, a farmer challenges the player to perform a movement combining elbow flexion and extension with internal and external rotation of the shoulder. These findings suggest the potential of the studied exergame as a tool for the upper limb rehabilitation of individuals who have experienced a stroke. Conclusions The inclusion of exergames in rehabilitation for stroke-induced hemiparesis has significantly benefited the recovery process by focusing on essential shoulder and elbow movements. These interactive games play a crucial role in helping users regain mobility and restore practical use of affected limbs. They also serve as valuable data sources for researchers, improving the system’s responsiveness. This iterative approach enhances game design and markedly boosts user satisfaction, suggesting exergames have promising potential as adjunctive elements in traditional therapeutic approaches.

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[BOOK Chapter] Dynamic Difficulty Adjustment (DDA) on a Serious Game Used for Hand Rehabilitation

Abstract

Serious games have been used for assisting people in physical rehabilitation for hands. People might have different degrees of mobility in their hands; consequently, it would be convenient that the game could be adapted according to the range-of-motion in performing hand movements. This study implemented a serious game for hand rehabilitation with two play modes. Mode one does not adjust the game difficulty; whereas mode two adjusts the game difficulty according to the player’s range-of-motion in performing flexion, extension, ulnar, and radial deviations. The game difficulty was adjusted using fuzzy logic to compute positions at which the rewards will be displayed at the game scene (easy, medium, and difficult positions to collect the rewards). Four participants played both modes. Two-tailed t-tests revealed that there were no significant differences between both modes in terms of rewards collected (p = 0.6621), play time (p = 0.8178), and “game engagement questionnaire” score (p = 0.1383).

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Introduction

Hands play a key role in daily activities. People use them to interact with the world. Nevertheless, due to accidents or medical conditions, people might lose mobility in their hands; consequently, they might require physical rehabilitation.

According to Walsh et al., (2002), “exercise forms a crucial part of a patient’s motor rehabilitation in terms of upper and lower limb function as well as prevention of muscle atrophy” (p. 2).

The main problem in the traditional rehabilitation method is the lack of motivation in patients; therefore, the performances of the rehabilitation exercises might become frustrated and boring. To cope with this issue, robots have been used to assist people during their motor rehabilitation exercises. For instance, a review on robots employed as assistive technologies for rehabilitation on upper limb can be found in (Narayan et al., 2021). In the same vein, robots have been employed for lower limb motor rehabilitation (Alvarez-Perez et al., 2020; Hussain et al., 2017, Hussain et al., 2021).

On the other hand, researchers (Lohse et al., 2013) have studied that video games can be used as a therapeutic tool in physical rehabilitation due to their motivational and engagement properties (e.g., optimal challenge, rewards and feedback provided to the players). As can be seen, these games are focused on assisting people in their rehabilitation processes. These types of games are called serious games. According to Zyda (2005), a serious game can be defined as “a mental contest, played with a computer in accordance with specific rules, that uses entertainment to further government or corporate training, education, health, public policy, and strategic communication objectives” (p. 26).

Figure 1. 

Wrist joints

It is important to remark that serious games have been used to assist therapists in the rehabilitation processes of patients on emotional health aspects (e.g., anxiety and depression (Abd-Alrazaq et al., 2022; Barnes & Prescott, 2018; Dias et al., 2018), autism spectrum disorder (Silva et al., 2021; Tsikinas & Xinogalos, 2019), phobias: acrophobia (Sharmili & Kanagaraj, 2020), spider phobia (Lindner et al., 2020)) and motor rehabilitation (e.g. ankle rehabilitation (Hendrickx et al., 2021, Feng et al., 2018), finger rehabilitation (Rahman, 2017; Aguilar-Lazcano & Rechy-Ramirez, 2020), shoulder rehabilitation (Viglialoro et al., 2020; Steiner et al., 2020)), so that the patients could be engaged to the rehabilitation and therapy. Additionally, virtual reality has been used in serious games for upper limb rehabilitation. For instance, Wang et al., (2022) conducted a review on game-based virtual reality systems for upper limb rehabilitation on people that have suffered a stroke to assess the effectiveness of these systems. As a result, authors found that games based on virtual reality for upper limb rehabilitation are more effective than traditional rehabilitation on people suffering cerebral apoplexy.

In terms of wrist motor rehabilitation, the majority of these games are controlled using rehabilitation exercises for the wrist (e.g., flexion, extension, ulnar and radial deviations, pronation and supination of the wrist). The wrist has two main joints, radiocarpal joint and midcarpal joint, that are involved in these rehabilitation exercises (see Figure 1). The intensities of the movements depend on the range-of-motion (ROM) that the patients might have in their hands. According to the American Physical Therapy Association (2001), the range-of-motion “is the arc of motion that occurs at a joint or a series of joints”.

Key Terms in this Chapter

Engagement: it is the feeling of enjoying playing the game (i.e., the involvement in the game).

Fuzzy Logic: It was introduced by Lotfi Zadeh in 1965. Fuzzy logic could be employed to tackle data uncertainty through mainly three processes: fuzzification, fuzzy inference, and defuzzification.

Range-of-Motion: The number of degrees – arc – that a joint could achieve when it is moved from one position to another.

Serious Game: It is a video game played against a computer, where its main purpose is beyond the entertainment (i.e., it is designed to tackle health problems or train people mainly).

Dynamic Difficulty Adjustment (DDA): The game difficulty is modified continuously in the game in order to avoid boredom or frustration on the player.

Leap Motion Controller: It is a sensor based on infrared cameras and leds, which can identify X, Y, Z coordinates of the positions of the finger phalanges, palm, wrist and elbow.

Rehabilitation: A process that is needed in order to recover mobility. This could be done using body movements or exercises.

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Preface

Maki K. Habib

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Process Mining in Production Management, Intelligent Control, and Advanced KPI for Dynamic Process Optimization: Industry 5.0 Production Processes (pages 1-17)

Alessandro Massaro

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The Explainable Model to Multi-Objective Reinforcement Learning Toward an Autonomous Smart System (pages 18-34)

Tomohiro Yamaguchi

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Dynamic Difficulty Adjustment (DDA) on a Serious Game Used for Hand Rehabilitation (pages 35-66)

Juan Ignacio Vargas-Bustos, Ericka Janet Rechy-Ramirez

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Evolution of Blockchain Technology: Principles, Research Trends and Challenges, Applications, and Future Directions (pages 67-104)

Oluwaleke Umar Yusuf, Maki K. Habib

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Mind of a Portfolio Investor: Which Strategies Should I Use as a Basis for My Investment Decisions (pages 105-119)

Chabi Gupta

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Modelling of Engineering Systems With Small Data: A Comparative Study (pages 120-136)

Morteza Mohammadzaheri, Mojtaba Ghodsi, Hamidreza Ziaiefar, Issam Bahadur, Musaab Zarog, Mohammadreza Emadi, Payam Soltani, Amirhosein Amouzadeh

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The Theory and Applications of the Software-Based PSK Method for Solving Intuitionistic Fuzzy Solid Transportation Problems (pages 137-186)

P. Senthil Kumar

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Metrics for Project Management Methodologies Elicitation (pages 187-212)

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An Overview of Security Issues in Cognitive Radio Ad Hoc Networks (pages 213-246)

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Energy Harvesting Systems: A Detailed Comparison of Existing Models (pages 247-295)

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Detecting Phishing URLs With Word Embedding and Deep Learning (pages 296-319)

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Prospects of Deep Learning and Edge Intelligence in Agriculture: A Review (pages 320-341)

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Study on Healthcare Security System-Integrated Internet of Things (IoT) (pages 342-362)

S. A. Karthik, R. Hemalatha, R. Aruna, M. Deivakani, R. Vijaya Kumar Reddy, Sampath Boopathi

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[Abstract] A Framework for Tele-rehabilitation Gaming System

Abstract

Brain damage resulting from stroke and traumatic brain injury is the primary cause of complicated disability and one of the major causes of mortality in most countries, burdening healthcare systems owing to the growth in the number of brain injury victims. Rehabilitation is required to deal with the brain damage. With fewer therapists available, it is very challenging to manage patients and even motivate them to participate actively in their rehabilitation. Patients have frequently complained that many traditional rehabilitation systems are monotonous and uninteresting. The study’s objective is to propose a telerehabilitation gaming system framework that can serve as guidance for developing an affordable rehabilitation gaming system that can motivate and engage patients and increase rehabilitation effectiveness. The research methodology is based on synthesizing related research and currently available technologies. The proposed framework includes the therapist and patient attached with vital constructs: tailoring tools, instructional content, game characteristics, tailored games, and performance. It is an internet-based communication structure that connects the Rehabilitation Gaming System to the hospital and other care provider networks. The proposed framework is evaluated by a panel of five experts. The results reveal that all experts believe that the proposed framework can serve as a useful guide for creating gaming interventions that can boost the patient’s motivation and engagement and increase the effectiveness of rehabilitation.

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[ARTICLE] Rehabotics: A Comprehensive Rehabilitation Platform for Post-Stroke Spasticity, Incorporating a Soft Glove, a Robotic Exoskeleton Hand and Augmented Reality Serious Games – Full Text

Abstract

Spasticity following a stroke often leads to severe motor impairments, necessitating comprehensive and personalized rehabilitation protocols. This paper presents Rehabotics, an innovative rehabilitation platform incorporating a multi-component design for the rehabilitation of patients with post-stroke spasticity in the upper limbs. This system incorporates a sensor-equipped soft glove, a robotic exoskeleton hand, and an augmented reality (AR) platform with serious games of varying difficulties for adaptive therapy personalization. The soft glove collects data regarding hand movements and force exertion levels when the patient touches an object. In conjunction with a web camera, this enables real-time physical therapy using AR serious games, thus targeting specific motor skills. The exoskeleton hand, facilitated by servomotors, assists patients in hand movements, specifically aiding in overcoming the challenge of hand opening. The proposed system utilizes the data collected and (in combination with the clinical measurements) provides personalized and refined rehabilitation plans and targeted therapy to the affected hand. A pilot study of Rehabotics was conducted with a sample of 14 stroke patients. This novel system promises to enhance patient engagement and outcomes in post-stroke spasticity rehabilitation by providing a personalized, adaptive, and engaging therapy experience.

1. Introduction

Stroke is one of the leading causes of long-term disability globally, frequently resulting in upper limb spasticity. Spasticity is characterized by increased muscle tone, stiffness, exaggerated tendon reflexes, involuntary activation of the muscles and resistance to passive movement [1], which significantly affects patients’ quality of life [2]. Rehabilitation, including physical therapy and occupational therapy, is a key part of recovery after a stroke. However, the amount of time that post-stroke patients typically spend in the hospital working on their upper limb rehabilitation is inadequate for achieving a full recovery of function [3,4].

Traditional physiotherapy, while crucial for recovery, often encounters challenges such as suboptimal patient engagement and lack of personalization. Serious games have demonstrated a significant enhancement in patient motivation [5]. Also, innovative technologies, such as robotic exoskeletons and augmented reality (AR), have shown promising results in rehabilitating patients with motor impairments [6]. This maximizes the results when paired with the presence of a therapist (as in traditional physiotherapy), allowing for immediate adjustment and personalization of therapy based on the patient’s performance and feedback. Nevertheless, in telerehabilitation, while immediate therapist feedback might not be possible, the use of advanced technologies like AR can enable real-time adaptation and personalization of therapy protocols. The concept of serious games in rehabilitation is not new. In 2009, Burke et al. determined the principles of game design suitable for upper limb stroke rehabilitation, and several games were developed and showcased based on these principles [5]. Based on this premise, the challenge of customizing games for rehabilitation purposes, as stated in [7], lies in rehabilitation complexity, as it often demands human involvement. For instance, research on game usability has been conducted where assessment involved interviewing both rehabilitators and their patients [4]. In a proposal by Rabin et al. [8], the impact of serious games on motor control was studied using a serious game that progressively increases in difficulty for upper-limb rehabilitation. The primary issue with this approach is the adjustment of game parameters. Hocine et al. [7] detailed a universal technique for adjusting the difficulty of games intended for upper-limb rehabilitation, focusing on modifying pointing tasks and creating game levels. González-González et al. [9] proposed a recommender system which is able to provide the user with personalized games according to their history and skills. Also, devices such as KINECT have been used to adjust the difficulty levels using a fuzzy system [10].

To enhance motor functions, exoskeleton hand rehabilitation robots have been frequently applied, mimicking human limbs in their design, while being attached to the patient at various locations and having joint axes that align with those of the human joints. Moreover, they can be anchored to a table or be either mobile or fixed relative to the patient’s body [11]. Long-term therapy also includes a significant financial burden of the patients involved, as well as the necessity for patients to physically attend therapy sessions. This contributes to diminished enthusiasm, potentially leading to a decline in quality of life.

Taking the above into account, these challenges highlight the need for innovative systems that can support both therapists and patients during the rehabilitation process. Robotic systems, for instance, can alleviate the physical strain experienced by therapists while facilitating more intensive and extended training periods for patients. This can expedite recovery and enable the more effective execution of repetitive action exercises [6,12]. In this paper, we propose an innovative platform, “Rehabotics”, that addresses these limitations by combining a soft glove for data collection, a robotic exoskeleton hand, and AR serious games, thereby offering a comprehensive, patient-centric, and engaging approach to post-stroke spasticity rehabilitation.

The paper is organized as follows: Section 2 describes the components and methodology involved in the proposed system. In Section 3, we present the results from our pilot study. Finally, Section 4 includes a discussion section, reflecting on the study’s results, highlighting the potential of the Rehabotics system to enhance rehabilitation outcomes while suggesting areas for future research and addressing the limitation of the study. […]

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Figure 2. (a) Soft glove photo; (b) graphs of pressure and bending sensors when hand is closed.

[ARTICLE] Virtual Reality Music Instrument Playing Game for Upper Limb Rehabilitation Training – Full Text

The motor function of the upper limb is typically impaired in stroke patients; as a result, rehabilitation exercise is crucial to regaining muscular control. While encouraging patients to continue with long-term exercise using standard rehabilitation training methods may be difficult. To deal with this dilemma, virtual reality (VR) games are introduced to motivate patients to take part in therapy. Meanwhile, music therapy has been proven to be extremely beneficial in the early phases of stroke recovery. These activities inspire us to include musical instrument play like xylophone and drums, in the design of VR games. By striking the xylophone’s highlighted keys or the flying notes aimed at the drums, the impaired upper limb functions can be strengthened. Early user evaluations demonstrate that the developed games are straightforward to use and appeal to patients’ desire for more exercise.

1 INTRODUCTION

Tangible games are widely utilized to motivate patients and track their performance to support therapists better [9, 10, 11], while some recent research studies also adopt virtual reality (VR) games in redesigning upper limb exercises. VR games and actual movements can be integrated together to motivate patients in rehabilitation exercises. Rose et al. [7] reported that patient enjoyment and willingness to participate were concluded in healthcare plans incorporating VR due to its immersive, entertaining approach to improving performance. However, some VR games may provide repetitive, intense, and task-specific training to enhance neuroplasticity [8]. In order to mitigate this issue, music therapy, which has been demonstrated to aid in both physical and mental rehabilitation, has been proven to be extremely beneficial in the early phases of stroke recovery [4]. Both sorts of engagement can benefit stroke patients, but generally speaking, low-cost methods have more real-world use. The price of VR-based headset has been extremely expensive in the past. With the improvement of technology, a few cost-effective VR devices are launched in the market, such as PICO4 (an all-in-one device around $425 as shown in Fig. 1), which creates more opportunities for VR game development. In this study, we focus on rhythm-based upper-limb training exercises by incorporating musical instrument playing into VR game design. As a result, the two musical instruments, i.e., the xylophone and drums, are applied to the game design with tactile, auditory, and visual feedback.

2 RELATED WORKS

Projects like TangiBoard demonstrated how sensory technology and tangibles can generally enrich learning and training experience in upper limb rehabilitation [5, 6]. In recent years, many projects aimed to tackle similar problems using VR technology by picking up and positioning objects in the virtual environment at specific places [6]. For example, the Bimeo gadget provided a VR environment to encourage patients to rehabilitation exercise, as well as support therapists to oversee and manage the exercise [1]. The ArmeoSenso system [5] similarly used VR and inertial measurement unit (IMU) for video game-based training and assessment of upper limb functions. VR games have been explored as tools in rehabilitation training.

Playing therapeutic instrumental music assists patients in regaining functional movement patterns and damaged motor functions [3]. Connie Tomaino, the director of the Beth Abraham Music and Neurologic Rehabilitation Institute, states that “focusing attention on rhythmic instruments can increase movement in individuals such as those with Parkinson’s disease or stroke rehabilitation patients” [2]. In music therapy, drums and xylophone are very popular instruments since people without prior knowledge can quickly learn how to play. In fact, stroke rehabilitation patients may exercise more if they concentrate on rhythmic instruments [2]. As a result, we decided to build a rhythm-based VR game using drums and xylophone play for rehabilitation exercise.

3 CONCEPTUAL DESIGN AND GAME PROTOTYPING

We observed patients performing arm-reaching exercises while conducting field research at a local rehabilitation facility, Suzhou Municipal Hospital, by moving a wooden instrument on the table. This exercise is vital to inhibit muscular contraction in the initial stages of stroke recovery. Patients moved from one posture to another as directed by therapists verbally. Even under the care of therapists, patients were quite inactive, although they could exercise independently. To sum up, we identify the design opportunity as providing a low-cost training device that motivates and guides patients through active exercising tasks. Meanwhile, therapists should be able to monitor multiple patients simultaneously and record their performances.

As a result, we created a VR game concept utilizing PICO4 to encourage them to complete the practice. The stroke patients held two controllers that weighed 185 grams each while wearing headsets. Through gripping the controllers, users can play virtual music instruments for upper limb reaching, stretching and extension. PICO4 device can mirror the VR display from the headsets to other devices such as televisions, computers, and smartphones. With this screen mirroring capability, clinicians could not only provide guidance and assistance to patients, but also monitor their gaming performance in real-time. Two distinct game modes are primarily designed: ‘Xylophone Play Mode’ and ‘Drums Play Mode’ to support appropriate upper limb functional training. Two iterations of VR game design are explored to facilitate arm reaching, shoulder extension, wrist and elbow rotation exercises.

Figure 1: PICO 4 Device

3.1 First Edition

In the ‘Xylophone Play Mode’, patients move virtual mallets by arm movement to strike the keys. A melody can be generated by pointing, rotating the wrist, and moving the mallet up and down to strike the keys. This game can improve upper limb-eye coordination and fine motor control.

In the ‘Drums Play Mode’, the rhythmical notes fly and move directly towards the corresponding drums with the background music. Patients use the virtual drumsticks to catch those notes above the drums, and successful strikes are rewarded with points. Clinicians can gauge the patients’ progress based on the scores received and decide whether they can move on to more challenging levels. For user-intuitive feedback, a successful note-catching would trigger a drum beat sound with controller vibration and an explosion effect. We tested our VR game in Suzhou Municipal Hospital Rehabilitation Center and received the following therapist response. Task-driven functionality, such as highlighting particular keys on xylophone to guide users exercise, should be included in the ‘Xylophone Play Mode’. The flight speed of such rhythmical notes in the ‘Drums Play Mode’ is too quick, which causes much miss catching in the exercise. As a result, two difficulty levels are designed for this mode in the revised version: basic level and standard level.

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