Archive for category Video Games/Exergames
[ARTICLE] Virtual reality experiences, embodiment, videogames and their dimensions in neurorehabilitation – Full Text
In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses. This represents a serious confounding factor that is leading to misleading, inconclusive outcomes in the interest of validating these new solutions.
Extending existing definitions of virtual reality, in this paper I put forward the concept of virtual reality experience (VRE), generated by virtual reality systems (VRS; i.e. a group of variable technologies employed to create a VRE). Then, I review the main components composing a VRE, and how they may purposely affect the mind and body of participants in the context of neurorehabilitation. In turn, VRS are not anymore exclusive from VREs but are currently used in videogames and other human-computer interaction applications in different domains. Often, these other applications receive the name of virtual reality applications as they use VRS. However, they do not necessarily create a VRE. I put emphasis on exposing fundamental similarities and differences between VREs and videogames for neurorehabilitation. I also recommend describing and evaluating the specific features encompassing the intervention rather than evaluating virtual reality or videogames as a whole.
This disambiguation between VREs, VRS and videogames should help reduce confusion in the field. This is important for databases searches when looking for specific studies or building metareviews that aim at evaluating the efficacy of technology-mediated interventions.
In the context of stroke rehabilitation, new training approaches mediated by virtual reality and videogames are usually discussed and evaluated together in reviews and meta-analyses for upper limb [1, 2], and balance and gait . Certainly, the expected superiority of virtual reality over conventional therapy post stroke has been questioned when using off-the-shelf (e.g., Nintendo Wii) or ad-hoc videogames. This conclusion, however, is based on the wrong assumption that videogames deliver same experiences than virtual reality applications. In my opinion, this represents a serious confounding factor that may lead to misleading, inconclusive outcomes in the interest of validating these new solutions. Indeed, in Laver’s Cochrane article, a positive effect for virtual reality versus conventional therapy for improving upper limb function post stroke is found only when dedicated virtual reality based interventions, i.e. specifically designed for rehabilitation settings, are used. The effect vanishes when standard off-the-shelf videogames are considered. Indeed, the use of Nintendo Wii (but referring to it as virtual reality) often leads to a non-inferiority clinical outcome, being as effective as conventional therapy  or alternative playful interventions such as playing cards . In another study with mobile-based and dedicated games (again referred to as virtual reality), partial functional and motor improvements were observed as compared to standard occupational therapy .
This heterogeneity in the reported virtual reality and videogames studies for neurorehabilitation calls for use of appropriate labelling for the approaches and variables assessed. A correct identification of the specific factors (and their weight) contributing to any eventual change post treatment are required for interpreting those changes and building further evidence on the specific solution. Therefore, in this paper I propose to reframe the traditional interpretation of the term virtual reality. I advocate disentangling two conceptual components that may help the field standardize its use: virtual reality experience (VRE) and virtual reality systems (VRS). I put emphasis on exposing fundamental similarities and differences between VREs and videogames, often mistakenly used as synonyms or exchangeable terms despite the different underlying interventional techniques and brain mechanisms they can enable. I then use neurorehabilitation as exemplary application field to discuss the implications of differentiating between them.[…]
[Abstract] BIGHand – A bilateral, integrated, and gamified handgrip stroke rehabilitation system for independent at-home exercise – Demo Video
Effective home rehabilitation is important for recovery of hand grip ability in post-stroke individuals. This paper presents BIGHand, a bilateral, integrated, and gamified handgrip stroke rehabilitation system for independent at-home exercise. BIGHand consists of affordable sensor-integrated hardware (Vernier hand dynamometers, Arduino Uno, interface shield) used to obtain real-time grip force data, and a set of exergames designed as parts of an interactive structural rehabilitation program. This program pairs targeted difficulty progression with user-ability scaled controls to create an adaptive, challenging, and enticing rehabilitation environment. This training prepares users for the many activities of daily living (ADLs) by targeting strength, bilateral coordination, hand-eye coordination, speed, endurance, precision, and dynamic grip force adjustment. Multiple measures are taken to engage, motivate, and guide users through the at-home rehabilitation process, including “smart” post-game feedback and in-game goals.
[ARTICLE] Barriers, Facilitators and Interventions to Support Virtual Reality Implementation in Rehabilitation: A Scoping Review – Full Text
Virtual reality and active video games (VR/AVGs) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice. However, clinical adoption remains low despite a growing evidence base and the recent development of clinically accessible and rehabilitation-specific VR/AVG systems. Given clinicians’ eagerness for resources to support VR/AVG use, a critical need exists for knowledge translation (KT) interventions to facilitate VR/AVG integration into clinical practice. KT interventions have the potential to support adoption by targeting known barriers to, and facilitators of, change. This scoping review of the VR/AVG literature uses the Theoretical Domains Framework (TDF) to (1) structure an overview of known barriers and facilitators to clinical uptake of VR/AVGs for rehabilitation; (2) identify KT strategies to target these factors to facilitate adoption; and (3) report the results of these strategies. Barriers/facilitators and evaluated or proposed KT interventions spanned all but 1 and 2 TDF domains, respectively. Most frequently cited barriers/facilitators were found in the TDF domains of Knowledge, Skills, Beliefs About Capabilities, Beliefs About Consequences, Intentions, Goals, Environmental Context and Resources, and Social Influences. Few studies empirically evaluated KT interventions to support adoption; measured change in VR/AVG use did not accompany improvements in self-reported skills, attitudes, and knowledge. Recommendations to target frequently identified barriers include technology development to meet end-user needs more effectively, competency development for end-users, and facilitated VR/AVG implementation in clinical settings. Subsequent research can address knowledge gaps in both clinical and VR/AVG implementation research, including on KT intervention effectiveness and unexamined TDF domain barriers.
Virtual reality and active video games (VR/AVG) are promising rehabilitation tools because of their potential to facilitate abundant, motivating, and feedback-rich practice [1,2]. A steady increase in the number of peer-reviewed articles evaluating the effects of VR/AVG interventions in many rehabilitation populations has been observed over the past 20 years. This increase reflects a growing interest in VR/AVG from the rehabilitation research and development sectors. Ideally, newly developed and empirically evaluated products and interventions that are found to be safe and effective would be quickly integrated into clinical practice. Yet what we are observing in patient care follows a more typical pattern for the adoption of evidence-based treatment techniques or tools: one of slow and variable progress .
Collaboration between engineers and product end-users can inform the development of useful VR/AVG technologies that meet the needs of clients and therapists. Moving VR/AVG technology into the hands of therapists allows clients to benefit from its therapeutic potential. Systematically examining the factors that impact VR/AVG adoption in rehabilitation, and the effect of knowledge translation (KT) strategies on behaviors related to their use, is critical for guiding the successful implementation of these technologies. A clear understanding of how VR/AVG is being used by clinicians, the limitations clinicians face in integrating the technologies into their daily treatment routines, and the most effective strategies for supporting clinicians in technology adoption are paramount to informing these implementation approaches.
Recent surveys of occupational and physical therapists in Canada , the United States (Levac et al., in preparation), and Scotland  on their use of VR/AVG and their learning needs related to future use of these technologies provides a foundational knowledge base about current clinical use. Nearly half of the 1071 respondents in Canada  and 76% of the 491 U.S. respondents (Levac et al., in preparation) had used VR/AVG clinically. However, only 12% of respondents in Canada , 31% in the United States (Levac et al., in preparation), and 18% of the 112 respondents in Scotland  reported current use. This discrepancy indicates the need for additional efforts to identify and to address existing barriers to VR/AVG use. Commercially available AVG systems were the most common systems in use in all 3 countries [4,5] (Levac et al., in preparation); the use of rehabilitation-specific VR systems by Canadian  and U.S. therapists (Levac et al., in preparation) was much lower (<3% of respondents for any given system).
Despite low reported daily use, VR/AVG systems were perceived by therapists to be widely relevant to rehabilitation for a number of different client populations, functional recovery goals and practice settings . Sixty-one percent of respondents in Scotland reported that they would use gaming if it were available to them . The majority of respondents in both Canada  (76.3%) and the United States (69.9%) (Levac et al., in preparation) reported low self-efficacy in using VR/AVG clinically, but were interested in learning more. Commonly reported learning needs included knowledge and skills in selecting appropriate systems and games for individual clients, grading activities, evaluating outcomes, and integrating theoretical approaches to treatment [4,6,7]. These findings suggest a strong need for educational resources and knowledge translation (KT) supports to facilitate evidence-based technology adoption [4,6]. KT is the process of moving evidence into practice . KT interventions have the potential to support adoption by targeting known barriers to change, including a lack of knowledge and skills .
Strong insights into the factors influencing therapists’ adoption of VR/AVG have emerged only in the past 5 years. A decomposed Theory of Planned Behavior, which integrates constructs from the Technology Adoption Model and the Diffusion of Innovation theory forms the theoretical basis for the majority of this research [4,6]. The Theoretical Domains Framework (TDF) is another approach that can be used to conceptualize the evaluation of barriers and facilitators of change, including technology adoption . The TDF is an implementation framework that integrates 128 theoretical constructs drawn from 33 behavior change theories into 14 barrier/facilitator domains . Although the framework has not been applied yet to this body of literature, it offers a more comprehensive approach to the identification and classification of barriers and facilitators of change than a single theory or framework alone. Drawn from the KT literature, the framework can be used to structure the assessment of barriers and facilitators of change across a range of contexts, as well as the selection of interventions to target these barriers and facilitators .
The purpose of this scoping review was to apply the TDF to examine the extent, range, and nature of studies assessing VR/AVG barriers and facilitators and/or recommending or evaluating KT interventions to promote VR/AVG adoption in rehabilitation since 2005. Our objectives were to
present an overview of factors known to limit or support VR/AVG adoption for rehabilitation;
describe the KT strategies that have been recommended or evaluated to address these factors and to report on their effectiveness, where possible; and
provide recommendations for technology development, research, and clinical implementation based on these findings.
Tired of using dumbbells for rehabilitation following distal radius fractures? Looking for new interventions to increase client engagement? Look no further than your patient’s smartphone! Incorporate it into exercise routines to help your patients regain wrist balance and to provide proprioceptive input.
Evidence Supports Proprioceptive Activities
Emerging evidence supports the use of proprioceptive activities for distal radius fracture rehabilitation.1 A cross-sectional study involving females treated operatively and non-operatively for a distal radius fracture found that participants had significantly less joint position sense in comparison to study controls.2 The proprioceptive limitations correlated highly with functional impairment on the Patient Rated Wrist Evaluation.3
By addressing proprioceptive deficits while encouraging functional wrist range of motion, smartphone applications complement a traditional hand therapy program for individuals requiring skilled therapy following a distal radius fracture.
Some games to consider:
- Chopper Lite – Action packed side-scrolling helicopter game where a tilt of the screen flies the chopper.
- Labyrinth – Classic labyrinth game in which you must guide a ball through a labyrinth by moving your device.
- Tilt Maze Lite – Maze game where a tilt of your device helps a marble through a maze toward the exit. Use different mazes to test wrist balance and timing. The game stores the player’s best time for each maze so patients can track their performance as their wrist heals.
- Water Slide Extreme – Unique water slide game featuring tight corners and huge loops that you must navigate by twisting or leaning your device.
- Snail Mail – Kart-style racing game in which the player controls a racing snail on a mission to collect packages and deliver them to the farthest reaches of the universe while dodging obstacles such as laser towers, slugs, asteroids, and salt.
The clinician should consider using smartphones as an intervention following distal radius fractures. Skilled hand therapists can assist with appropriate postural mechanics and provide guidelines for the amount of time a patient should devote to gaming.
Rehabilitation at Your Fingertips
Certain smartphone applications can be used to address client-specific deficits, decrease functional concerns, and achieve client-centered goals. Incorporating smartphone gaming in hand therapy may provide motivation and convenience to your clients.
- Algar, L., & Valdes, K. (2014). Using smartphone applications as hand therapy interventions. Journal of Hand Therapy, 27(3), 254–257. doi:10.1016/j.jht.2013.12.009
- Karagiannopoulos, C., Sitler, M., Michlovitz, S., & Tierney, R. (2014a). A Descriptive Study on Wrist and Hand Sensori-Motor Impairment and Function Following Distal Radius Fracture Intervention. Journal of Hand Therapy, 27(3), e2–e3. doi:10.1016/j.jht.2013.08.006
- Karangiannopoulos, et al. (2014)
[Abstract] Game-based hand resistance exercise versus traditional manual hand exercises for improving hand strength, motor function, and compliance in stroke patients: A multi-center randomized controlled study
Game-based exercise is effective for improving strength and motor function in stroke patients undergoing rehabilitation, and it creates fun and motivation for exercise.
We investigated the effect of game-based exercise on hand strength, motor function, and compliance in stroke patients.
Fifty stroke patients were randomly divided into experimental and control groups. The experimental group performed a game-based hand resistance exercise. This exercise was divided into isotonic and isometric types and was performed 30 min/day, 5 days/week, for 6 weeks with 70% of the 1-repetition maximum. In contrast, the control group was given a traditional manual exercise by the occupational therapist, and the type of exercise and time involved were the same as those in the experimental group. The primary outcome measure was hand strength test measured using a dynamometer. Secondary outcome measures were manual function tests (MFT) and hand function tests using box and block test (BBT). Subject-based reports of motivation, fun, pain/fatigue evaluated on 0 to 10 numeric rating scales were compared between groups.
After training, hand strength, MFT and BBT was improved in the experimental group compared to the control group (P < 0.001, both). Subject-based reports of motivation and fun was significantly greater in the experimental group than the control group (P < 0.001, both), except to pain/fatigue (P = 0.728).
In conclusion, we demonstrated that game-based exercise is more effective than manual exercise in improving muscle strength, motor function, and compliance in stroke patients.
Rutgers virtual reality tools show promise for at-home stroke recovery
A small propeller plane operated by Allen DeNiear climbs into the sky. With a stark desert valley, seemingly inhabited by nothing more than cacti, visible on the red earth below, DeNiear makes a small motion with his hand. The plane pitches downward and dives.
DeNiear is not a pilot.
Nevertheless, his eyes focus on his targets, a series of orbs floating in the sky at various altitudes. His goal is simple enough: collect the orbs without crashing.
His reality, for the moment, is virtual.
Ready, player one.
Sitting in a lab at the Rutgers School of Health Professions in Newark, DeNiear moves his hand again. In his lap, a small infrared camera linked to the computer running the virtual reality (VR) flight simulator registers his hand movement. The plane ascends, and he collects another orb.
Both the motion and the game seem deceptively easy, but for DeNiear, who is recovering from a stroke and has limited mobility in his right hand, arm, and shoulder, the move is more than meets the eye, and the game, which can be played from anywhere you can fit a laptop, could wind up revolutionizing physical therapy treatments for stroke victims.
Today, DeNiear is with his Rutgers recovery team. But tomorrow, when he needs to do therapeutic work on his hand and arm, he’ll do it from home. No appointment is needed, the trek to a rehab center is eliminated, and—because the games are a lot more fun than monotonous rehab programs—he is more likely to actually do his exercises, thanks to the at-home approach to rehabilitation being tested and refined by Rutgers researchers.
Improving at-home therapy’s low score.
Standard at-home physical therapy regimens for stroke recovery are both boring and frustrating for patients. “The adherence to home exercise programs is incredibly low,” said Gerry Fluet, an associate professor in the rehabilitation and movement sciences department. A physical therapist by trade, Fluet’s research is focused on using VR games to increase patient participation in at-home therapy programs.
“We’re trying to create something that’s more pleasurable and interesting than opening your hand 50 times while you watch it and wish it would move more,” he said. “We set out to develop simulations that people would stop in the middle of their day to play, and tomorrow, pick them up and play them again, and then again the day after that.”
By building the physical rehabilitation regimen into a game, Fluet and his team are able to turn the monotony of stroke rehabilitation into something that is a lot more fun than it used to be. This is important, he said, because after a stroke, a person must put in a lot of work to regain control of the hand.
Without gaming therapy, people are exercising at home two or three times a week, for about five to 10 minutes, if they even bother doing it at all, Fluet said. Meanwhile, people in the lab’s study using the VR games at home are averaging anywhere from 60 to 90 minutes of exercise therapy in a week, with no additional reminders or encouragement. In the real world, this could translate into a much more cost effective and impactful form of stroke rehabilitation.
“We’re seeing tangible, measurable results,” he said.
The game library developed so far has a dozen titles. In addition to piloting a plane, players can drive a car, run through a maze, hit the keys of a piano, and more—all from a Windows-based application developed by Fluet’s long-time collaborator Qinyin Qiu, an assistant professor in the Department of Rehabilitation and Movement Sciences at Rutgers, and Amanda Cronce, a digital designer in the Department of Biomedical Engineering at New Jersey Institute of Technology (NJIT), as part of a collaboration between Rutgers Biomedical and Health Sciences and the Motor Control and Rehabilitation Lab led by Sergei Adamovich at NJIT.
The study has patients play the VR games at home for at least 15 minutes a day, every day for three months. The gaming application collects the patient data and transfers it to a remote data server so Qiu and Fluet can monitor the at-home progress. They can even use the application real-time chat with the patient.
“We’re really trying to turn this into tele-rehab,” said Qiu, adding that the team is exploring go-to-market strategies and commercialization opportunities for their project through an I-Corps grant.
DeNiear is, self-admittedly, “not a video game person,” but he embraces gaming as a method for recovering from his stroke. “As you’re playing the game, it breaks the monotony of what you’re supposed to be doing. If I didn’t have the games, it would be a lot slower,” he said of his recovery. “It helped speed the process up, I think.”
Today, DeNiear has regained enough mobility to be able to drive again, and write with his right hand. He is still not 100 percent recovered, and he acknowledges that he may never be totally back to his old self. But he is committed to making the most of his situation by taking advantage of opportunities to participate in studies like Fluet and Qiu’s at-home VR physical therapy program.
“You gotta work at it,” he said. “You gotta do it.”
[Systematic Review] Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients’ Rehabilitation: Systematic Review – Full Text
Background: Robot-assisted therapy has become a promising technology in the field of rehabilitation for poststroke patients with motor disorders. Motivation during the rehabilitation process is a top priority for most stroke survivors. With current advancements in technology there has been the introduction of virtual reality (VR), augmented reality (AR), customizable games, or a combination thereof, that aid robotic therapy in retaining, or increasing the interests of, patients so they keep performing their exercises. However, there are gaps in the evidence regarding the transition from clinical rehabilitation to home-based therapy which calls for an updated synthesis of the literature that showcases this trend. The present review proposes a categorization of these studies according to technologies used, and details research in both upper limb and lower limb applications.
Objective: The goal of this work was to review the practices and technologies implemented in the rehabilitation of poststroke patients. It aims to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies (VR, AR, or gamification) in improving activity and participation in poststroke survivors.
Methods: A systematic search of the literature on exoskeleton robotics applied with any of the three technologies of interest (VR, AR, or gamification) was performed in the following databases: MEDLINE, EMBASE, Science Direct & The Cochrane Library. Exoskeleton-based studies that did not include any VR, AR or gamification elements were excluded, but publications from the years 2010 to 2017 were included. Results in the form of improvements in the patients’ condition were also recorded and taken into consideration in determining the effectiveness of any of the therapies on the patients.
Results: Thirty studies were identified based on the inclusion criteria, and this included randomized controlled trials as well as exploratory research pieces. There were a total of about 385 participants across the various studies. The use of technologies such as VR-, AR-, or gamification-based exoskeletons could fill the transition from the clinic to a home-based setting. Our analysis showed that there were general improvements in the motor function of patients using the novel interfacing techniques with exoskeletons. This categorization of studies helps with understanding the scope of rehabilitation therapies that can be successfully arranged for home-based rehabilitation.
Conclusions: Future studies are necessary to explore various types of customizable games required to retain or increase the motivation of patients going through the individual therapies.
Stroke refers to a sudden, often catastrophic neurological event that can lead to long-term adult disability. The American Heart Association (AHA) is responsible for providing up-to-date statistics related to heart disease and stroke. According to Benjamin et al , the AHA released a 2017 statistics report on heart disease and stroke that stated that approximately 795,000 stroke episodes occur in the US each year. With current advancements in medical technology there has been a decrease in the rate of stroke incidents, but it can still cause paralysis and muscle weakness. Such impairments can result in motor deficits that disturb a stroke survivor’s capacity to live independently.
There are several reasons for stroke occurrence, which could be related to an increased risk of a collection of symptoms caused by disorders affecting the brain (eg, dementia) . Various rehabilitation techniques have been used in the area of rehabilitation-based interactive technology to assist patients in recovering from impairments, and those techniques come under the umbrella of conventional therapy, exoskeleton or robot-aided therapy, virtual reality (VR) or augmented reality (AR) therapy, games-based therapy, or a combination of any of these. These forms of therapy can be done either in the clinic or in an in-home setting. In addition to these, there is a new technology known as telerehabilitation [ ] that leverages the use of VR in home settings by providing patients access to real-time rehabilitation services through the internet while they sit at home.
One of the most effective techniques is robot-aided therapy, which has been gradually increasing in use primarily because patients may consider traditional rehabilitation therapy to be tiring and exhaustive. This may decrease their motivation and cohesion to the treatment, thus resulting in only minor improvement in the health of poststroke patients [– ]. Various experimental evidence suggests that robot-assisted (or exoskeleton) rehabilitation has been effective in keeping patients motivated and interested in treatment for both upper or lower limb impairments [ , ]. With advancements in technology, there has also been an uptake of VR, AR, and Gamification for the purposes of rehabilitation [ ], along with robotic rehabilitation [ , ], primarily to increase engagement, immersion and motivation on behalf of the patient. Both Colombo et al and Alankus et al [ , ] concluded and showed the positive effect of exoskeleton robots and games in poststroke rehabilitation. Wearable devices such as exoskeletons can also relay real-time feedback for any VR-based interactions [ ].
Apart from these studies, Housman et al  showed user satisfaction survey results in which 90% of participants agreed to the fact that robot- or games-assisted therapies were less confusing, and improvements were very easy to track compared to traditional or conventional therapies. Further, it is thought that gamification can increase repetition, engagement, and range of care within the context of rehabilitation [ , ]. Games are not only useful for the field of rehabilitation, but they are also considered to be highly impactful and relevant in other medical and health fields. Russoniello et al [ ] conducted a randomized controlled trial (RCT) study in which the effects of video games on stress-related disorders were tested, with the conclusion being that games were beneficial for their prevention and treatment. In another study, children who had cerebral palsy made use of a game (EyeToy) which was able to improve their upper extremity functions over time [ ].
Continue —-> JRAT – Exoskeletons With Virtual Reality, Augmented Reality, and Gamification for Stroke Patients’ Rehabilitation: Systematic Review | Mubin | JMIR Rehabilitation and Assistive Technologies
[Abstract] Effects of Exergame on Patients’ Balance and Upper Limb Motor Function after Stroke: A Randomized Controlled Trial.
Stroke is a major cause of motor incapacity in adults and the elderly population, requiring effective interventions capable of contributing to rehabilitation. Different interventions such as use of exergames are being adopted in the motor rehabilitation and balance area, as they act as motivating instruments, making therapies more pleasurable.
The aim of this study was to investigate the effects of exergame on patients’ balance and upper limb motor function after stroke.
This study is a randomized controlled trial. Thirty-one participants of both genders, mean age of 76 years, were assigned to the experimental or control groups; the experimental group (n = 16) underwent exergame rehabilitation using Motion Rehab AVE 3D, and the control group (n = 15) underwent conventional physiotherapy. Both EG and GC sessions happened twice a week, for 30 minutes each, over a 12 weeks period, resulting in 24 sessions. All sessions were composed of similar exercises, with same purpose and elapsed time (5 minutes). Instruments applied to verify inclusion criteria were a sociodemographic questionnaire and clinical aspects and a Mini-Mental State Examination. At baseline and after 12 weeks of intervention, the Modified Ashworth Scale, the Fugl-Meyer Assessment, and the Berg Balance Scale were used.
In both groups, patients obtained significant improvement from baseline values in all analyzed variables (shoulder, elbow, and forearm; wrist; hand; and balance) (P < .001). In the intergroup comparison, there were significant differences between the 2 groups for changes in values from preintervention to postintervention of shoulder, elbow and forearm (P = .001), and total (P = .002).
Exergame rehabilitation in poststroke patients can be an efficient alternative for restoring balance and upper limb motor function and might even reduce treatment time.