Posts Tagged Game
[ARTICLE] Rehabilitation via HOMe-Based gaming exercise for the Upper limb post Stroke (RHOMBUS): a qualitative analysis of participants’ experience – Full Text
Posted by Kostas Pantremenos in Paretic Hand, Tele/Home Rehabilitation, Video Games/Exergames on January 25, 2024
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 […]
[BOOK Chapter] Dynamic Difficulty Adjustment (DDA) on a Serious Game Used for Hand Rehabilitation
Posted by Kostas Pantremenos in Books, Paretic Hand, Video Games/Exergames on January 14, 2024
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).
Chapter Preview
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.
Complete Chapter List
Search this Book:
Reset
Table of Contents
Detailed Table of Contents
Preface
Maki K. Habib
Chapter 1
Alessandro Massaro
$37.50
Add to Cart
Chapter 2
The Explainable Model to Multi-Objective Reinforcement Learning Toward an Autonomous Smart System (pages 18-34)
Tomohiro Yamaguchi
$37.50
Add to Cart
Chapter 3
Dynamic Difficulty Adjustment (DDA) on a Serious Game Used for Hand Rehabilitation (pages 35-66)
Juan Ignacio Vargas-Bustos, Ericka Janet Rechy-Ramirez
$37.50
Add to Cart
Chapter 4
Evolution of Blockchain Technology: Principles, Research Trends and Challenges, Applications, and Future Directions (pages 67-104)
Oluwaleke Umar Yusuf, Maki K. Habib
$37.50
Add to Cart
Chapter 5
Mind of a Portfolio Investor: Which Strategies Should I Use as a Basis for My Investment Decisions (pages 105-119)
Chabi Gupta
$37.50
Add to Cart
Chapter 6
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
$37.50
Add to Cart
Chapter 7
The Theory and Applications of the Software-Based PSK Method for Solving Intuitionistic Fuzzy Solid Transportation Problems (pages 137-186)
P. Senthil Kumar
$37.50
Add to Cart
Chapter 8
Metrics for Project Management Methodologies Elicitation (pages 187-212)
Patricia R. Cristaldo, Daniela Lopez De Luise, Lucas La Pietra
$37.50
Add to Cart
Chapter 9
An Overview of Security Issues in Cognitive Radio Ad Hoc Networks (pages 213-246)
Noman Islam, Muhammad Furqan Zia, Darakhshan Syed
$37.50
Add to Cart
Chapter 10
Energy Harvesting Systems: A Detailed Comparison of Existing Models (pages 247-295)
Afnan Khaled Elhamshari, Maki K. Habib
$37.50
Add to Cart
Chapter 11
Detecting Phishing URLs With Word Embedding and Deep Learning (pages 296-319)
Ali Selamat, Nguyet Quang Do, Ondrej Krejcar
$37.50
Add to Cart
Chapter 12
Prospects of Deep Learning and Edge Intelligence in Agriculture: A Review (pages 320-341)
Ali Shaheen, Omar F. El-Gayar
$37.50
Add to Cart
Chapter 13
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
$37.50
Add to Cart
About the Contributors View Full PDF
Index View Full PDF
[Abstract] Use of an EMG-controlled game as a therapeutic tool to retrain hand muscle activation patterns following stroke – A pilot study
Posted by Kostas Pantremenos in Paretic Hand, Video Games/Exergames on February 2, 2022
By Na Jin Seo; Alex Barry; Mohammad Ghassemi; Kristen M Triandafilou; Mary Ellen Stoykov; Lynn Vidakovic; Elliot Roth; Derek G Kamper
Provisional Abstract:
Background/Purpose: To determine the feasibility of training with electromyographically (EMG)-controlled games to improve control of muscle activation patterns in stroke survivors.
Methods: Twenty chronic stroke survivors (>6 months) with moderate hand impairment were randomized to train either unilaterally (paretic only) or bilaterally over 9 one-hour training sessions. EMG signals from the unilateral or bilateral limbs controlled a cursor location on a computer screen for gameplay. The EMG muscle activation vector was projected onto the plane defined by the first two principal components of the activation workspace for the non-paretic hand. These principal components formed the x- and y-axes of the computer screen.
Results: The recruitment goal (n=20) was met over 9 months, with no screen failure, no attrition and 97.8% adherence rate. After training, both groups significantly decreased the time to move the cursor to a novel sequence of targets (p=0.006) by reducing normalized path length of the cursor movement (p=0.005), and improved the Wolf Motor Function Test (WMFT) quality score (p=0.01). No significant group difference was observed. No significant change was seen in the WMFT time or Box and Block Test.
Discussion/Conclusion: Stroke survivors could successfully use the EMG-controlled games to train control of muscle activation patterns. While the non-paretic limb EMG was used in this study to create target EMG patterns, the system supports various means for creating target patterns per user desires. Future studies will employ training with the EMG-controlled games in conjunction with functional task practice for a longer intervention duration to improve overall hand function.
[ARTICLE] Web Platform for Visualisation of Kinematic Data captured from a Motor Tele-rehabilitation System – Full Text PDF
Posted by Kostas Pantremenos in Music/Music therapy, REHABILITATION, Tele/Home Rehabilitation, Video Games/Exergames on December 16, 2021
Abstract
Stroke can have a severe impact on an individual’s quality of life, leading to consequences such as motor loss and communication problems, especially among the elderly. Studies have shown that early and easy access to stroke rehabilitation can improve an elderly individual’s quality of life, and that telerehabilitation is a solution that facilitates this improvement. In this work, we visualize movement to music during rehabilitation exercises captured by the Kinect motion sensor, using a dedicated Serious Game called `Move to the Music'(MoMu). Our system provides a quantitative view of progress made by patients during a motor rehabilitation regime for healthcare professionals to track remotely (tele-rehab).
[ARTICLE] A Depth Camera–Based, Task-Specific Virtual Reality Rehabilitation Game for Patients With Stroke: Pilot Usability Study – Full Text
Posted by Kostas Pantremenos in REHABILITATION, Video Games/Exergames, Virtual reality rehabilitation on March 31, 2021
Abstract
Background:The use of virtual reality is popular in clinical rehabilitation, but the effects of using commercial virtual reality games in patients with stroke have been mixed.
Objective:We developed a depth camera–based, task-specific virtual reality game, Stomp Joy, for poststroke rehabilitation of the lower extremities. This study aims to assess its feasibility and clinical efficacy.
Methods:We carried out a feasibility test for Stomp Joy within representative user groups. Then, a clinical efficacy experiment was performed with a randomized controlled trial, in which 22 patients with stroke received 10 sessions (2 weeks) of conventional physical therapy only (control group) or conventional physical therapy plus 30 minutes of the Stomp Joy intervention (experimental group) in the clinic. The Fugl-Meyer Assessment for Lower Extremity (FMA-LE), Modified Barthel Index (MBI), Berg Balance Scale (BBS) score, single-leg stance (SLS) time, dropout rate, and adverse effects were recorded.
Results:This feasibility test showed that Stomp Joy improved interest, pressure, perceived competence, value, and effort using the Intrinsic Motivation Inventory. The clinical efficacy trial showed a significant time-group interaction effect for the FMA-LE (P=.006), MBI (P=.001), BBS (P=.004), and SLS time (P=.001). A significant time effect was found for the FMA-LE (P=.001), MBI (P<.001), BBS (P<.001), and SLS time (P=.03). These indicated an improvement in lower extremity motor ability, basic activities of daily living, balance ability, and single-leg stance time in both groups after 2 weeks of the intervention. However, no significant group effects were found for the FMA-LE (P=.06), MBI (P=.76), and BBS (P=.38), while a significant group interaction was detected for SLS time (P<.001). These results indicated that the experimental group significantly improved more in SLS time than did the control group. During the study, 2 dropouts, including 1 participant who fell, were reported.
Conclusions:Stomp Joy is an effective depth camera–based virtual reality game for replacing part of conventional physiotherapy, achieving equally effective improvement in lower extremity function among stroke survivors. High-powered randomized controlled studies are now needed before recommending the routine use of Stomp Joy in order to confirm these findings by recruiting a large sample size.
Introduction
There are 800,000 new or recurring incidences of stroke annually in the United States; the number is rising as the population ages. More than half of stroke survivors live with at least one type of motor impairment [1]. In China, there are approximately 2 million incidences of a stroke every year. Among these stroke survivors, 70% to 80% cannot live independently as a result of multiple impairments, such as motor impairments with loss of strength, stereotypic movements, changes in muscle tone, and limitations in activities [2]. For many patients with stroke, balance and weight shift management constitute a risk for secondary injury. Lower extremity (LE) functional deficits in patients after stroke have aroused a great amount of attention because they play a vital role in stroke survivors’ quality of life [1,2]. Although stroke (new and recurring) remains prevalent, the number of available therapists is far from meeting the need, since the development of physical therapy has still not matured [3,4]. Rehabilitation technologies have the potential to increase the intensity and dose of rehabilitation, improve access to rehabilitation, reduce the workload of therapists, measure and provide feedback about performance and recovery, and engage and motivate patients [5–7]. Evidence-based medicine shows that high-intensity, repetitive, task-specific training tends to benefit patients greatly [8]. However, it is difficult to implement high-intensity, repetitive, task-specific training in a real clinical setting for a variety of reasons, including limited necessary resources and difficulty maintaining patients’ interest. Therefore, virtual reality–based gaming systems have become popular in medical rehabilitation and can be used as a novel alternative therapy method for motor recovery after stroke.
Kinect (Microsoft) is the leader in commercially available low-cost virtual reality (VR) hardware. This is because most of the Kinect’s games are aimed at the average person, and there are many more games designed by research teams for people with stroke, especially for upper limb motor function. However, there are few games focused on lower limb motor function [9]. VR, also known as immersive multimedia or computer-simulated reality, is a computer technology that replicates an environment, real or imagined, and simulates the user’s physical presence and environment to allow for user interaction and immersion. Virtual realities artificially create sensory experience, which can include sight, touch, hearing, and smell [10]. VR systems consist of a development platform, display system, interaction system, and integrated control system [11]. To realize the complete information interaction between computers and humans, normally we need some external device or devices to record the user’s movements. Among the kinds of external devices are force or tactile feedback systems, position trackers, data gloves or 6-degrees-of-freedom space mice, joysticks, and the Kinect sensor [11–13]. Kinect allows users to play without holding a game controller, which means they will not be bothered by wearing sensors that can be intrusive. This also saves time. Zhu et al [14] showed that the Kinect motion capture system was reliable and that the correlation coefficient of the dynamic track was quite good. A large number of clinical studies have shown that the accuracy of the Kinect somatosensory technology sensor for posture control and evaluation can fully meet the needs of body motion evaluation [15–17]. Eltoukhy et al [18] indicated that Kinect-based assessment might provide clinicians a simple tool to simultaneously assess reach distances while developing a clearer understanding of lower extremity movement patterns. Park et al [19] showed that the use of additional VR training with the Xbox Kinect gaming system was an effective therapeutic approach for improving motor function during stroke rehabilitation.
However, these systems were not specifically developed for patients after stroke, and those training sessions might produce multiple effects [20]. Those studies did not assess the flow experience of users, and few of them conducted a clinical randomized controlled trial. To address these issues, we developed a depth camera–based game, Stomp Joy, specifically for the lower limbs of patients with stroke. We also applied two principles of game design that are highly relevant to rehabilitation. The aim of this study was twofold: (1) develop a depth camera–based, task-oriented rehabilitation game for patients with stroke and (2) assess its usability and conduct a pilot study for stroke survivors’ LE rehabilitation.[…]
[Abstract] Attention Enhancement and Motion Assistance for Virtual Reality-Mediated Upper-limb Rehabilitation
Posted by Kostas Pantremenos in Paretic Hand, REHABILITATION, Video Games/Exergames, Virtual reality rehabilitation on October 30, 2020
Abstract
Dysfunctions of upper limbs caused by diseases such as stroke result in difficulties in conducting day-to-day activities. Studies show that rehabilitation training using virtual reality games is helpful for patients to restore arm functions. It has been found that ensuring active patient participation and effort devoting in the process is very important to obtain better training results. This paper introduces a method to help patients increase their engagement and provide motion assistance in virtual reali-ty-mediated upper-limb rehabilitation training. Attention en-hancement and motion assistance is achieved through an illusion of virtual forces created by altering the drag speed between the cursor and the object presented on a screen to the patient as the only feedback. We present two game forms using the proposed method, including a target-approaching game and a maze-following game. The results of evaluation experiments with human participants showed that the proposed method could provide path guidance that significantly improved path-following performance of users and required more involvement of the users when compared to playing the game without attention enhance-ment and motion assistance.
[Abstract] Design of Dynamic Tangible Workspaces for Games: Application on Robot-Assisted Upper Limb Rehabilitation
Posted by Kostas Pantremenos in Paretic Hand, REHABILITATION, Rehabilitation robotics, Video Games/Exergames on October 20, 2020
Abstract
A key element for the success of any game is its ability to produce a different experience at each round, thus keeping the player engagement high. This is particularly important for those games that also have a serious objective, such as gamified rehabilitation systems, aiming at encouraging patients in performing home rehabilitation exercises. In all cases, a game element which is typically static is the workspace, i.e. the “floor” upon which the game takes place. This is especially true for robot-assisted rehabilitation games, where the workspace must satisfy the requirements given by the robot’s locomotion and localization systems, as well as the patient’s exercise motion requirements.In this article we present a simple yet effective solution for designing dynamic and customizable tangible workspaces, which relies on hexagonal tiles and our previously proposed Cellulo localization system. These “hextiles” can be easily tangibly rearranged at each game round to yield a desired workspace shape and configuration, allowing tabletop mobile robots to move continuously within each new workspace. We ground our solution in the context of robot-assisted rehabilitation, where high adaptability is crucial for the efficacy of the solution, and propose a dynamic extension of our “tangible Pacman” rehabilitation game.Experiments show that the proposed solution allows for adaptation in range of motions, exercise types, physical and cognitive difficulty, besides reducing repetitiveness.
[Abstract] Design and development of a sensored glove for home-based rehabilitation
Posted by Kostas Pantremenos in Paretic Hand, REHABILITATION, Tele/Home Rehabilitation, Video Games/Exergames on September 13, 2020
Highlights
• In this article, we presented a newly develop sensor glove as an engaging rehabilitation method for individuals with hand dysfunctions.
• The developed system will enable the therapists to monitor the patient’s progress through the player’s score in the game that is recorded in a progressive log.
• The preliminary results supported that the exercise training using the sensor glove is repetitious, functional, and easy to follow and comply with.
Abstract
Study Design
Descriptive.
Introduction
Rehabilitation programs that focus on motor recovery of the upper limb require long-term commitment from the clinicians/therapists, require one-to-one caring, and are usually labor-intensive.
Purpose of the Study
To contribute to this area, we have developed a sensored hand glove integrated with a computer game (Flappy Bird) to engage patients playing a game where the subject’s single/multiple fingers are involved, representing fine motor skill occupational therapeutic exercises.
Methods
We described the sensored rehab glove, its hardware design, electrical and electronic design and instrumentation, software design, and pilot testing results.
Results
Experimental results supported that the developed rehab glove system can be effectively used to engage a patient playing a computer game (or a mobile phone game) that can record the data (ie, game score, finger flexion/extension angle, time spent in a therapeutic session, etc.) and put it in a format that could be easily read by a therapist or displayed to the therapists/patients in different graph formats.
Conclusions
We introduced a sensored rehab glove for home-based therapy. The exercise training using the glove is repetitious, functional, and easy to follow and comply with.
Source: https://www.sciencedirect.com/science/article/abs/pii/S0894113020300715?dgcid=rss_sd_all
[ARTICLE] Acceptability of a Mobile Phone–Based Augmented Reality Game for Rehabilitation of Patients With Upper Limb Deficits from Stroke: Case Study – Full Text
Posted by Kostas Pantremenos in Paretic Hand, REHABILITATION, Video Games/Exergames, Virtual reality rehabilitation on September 8, 2020
ABSTRACT
Background: Upper limb functional deficits are common after stroke and result from motor weakness, ataxia, spasticity, spatial neglect, and poor stamina. Past studies employing a range of commercial gaming systems to deliver rehabilitation to stroke patients provided short-term efficacy but have not yet demonstrated whether or not those games are acceptable, that is, motivational, comfortable, and engaging, which are all necessary for potential adoption and use by patients.
Objective: The goal of the study was to assess the acceptability of a smartphone-based augmented reality game as a means of delivering stroke rehabilitation for patients with upper limb motor function loss.
Methods: Patients aged 50 to 70 years, all of whom experienced motor deficits after acute ischemic stroke, participated in 3 optional therapy sessions using augmented reality therapeutic gaming over the course of 1 week, targeting deficits in upper extremity strength and range of motion. After completion of the game, we administered a 16-item questionnaire to the patients to assess the game’s acceptability; 8 questions were answered by rating on a scale from 1 (very negative experience) to 5 (very positive experience); 8 questions were qualitative.
Results: Patients (n=5) completed a total of 23 out of 45 scheduled augmented reality game sessions, with patient fatigue as the primary factor for uncompleted sessions. Each patient consented to 9 potential game sessions and completed a mean of 4.6 (SE 1.3) games. Of the 5 patients, 4 (80%) completed the questionnaire at the end of their final gaming session. Of note, patients were motivated to continue to the end of a given gaming session (mean 4.25, 95% CI 3.31-5.19), to try other game-based therapies (mean 3.75, 95% CI 2.81-4.69), to do another session (mean 3.50, 95% CI 2.93-4.07), and to perform other daily rehabilitation exercises (mean 3.25, 95% CI 2.76-3.74). In addition, participants gave mean scores of 4.00 (95% CI 2.87-5.13) for overall experience; 4.25 (95% CI 3.31-5.19) for comfort; 3.25 (95% CI 2.31-4.19) for finding the study fun, enjoyable, and engaging; and 3.50 (95% CI 2.52-4.48) for believing the technology could help them reach their rehabilitation goals. For each of the 4 patients, their reported scores were statistically significantly higher than those generated by a random sampling of values (patient 1: P=.04; patient 2: P=.04; patient 4: P=.004; patient 5: P=.04).
Conclusions: Based on the questionnaire scores, the patients with upper limb motor deficits following stroke who participated in our case study found our augmented reality game motivating, comfortable, engaging, and tolerable. Improvements in augmented reality technology motivated by this case study may one day allow patients to work with improved versions of this therapy independently in their own home. We therefore anticipate that smartphone-based augmented reality gaming systems may eventually provide useful postdischarge self-treatment as a supplement to professional therapy for patients with upper limb deficiencies from stroke.
Introduction
Background
Stroke induces a variety of functional impairments, as well as pain and other ailments, depending on its type and location [1]. Common deficits associated with ischemic stroke include motor function, spatial neglect, and psychological changes [1]. Motor function deficits after stroke often include partial or total loss of function of the upper or lower limbs on a given side, with associated muscle weakness, poor stamina, lack of muscle control, and even paralysis [2]. These deficits impact the patient’s independent lifestyle and decrease their performance of activities of daily living [1]. According to the National Institute of Neurological Disorders and Stroke, the most important part of rehabilitation programs is “carefully directed, well-focused, repetitive practice [3].”
Prior Work
Patients who engage in rigorous, time-intensive, and challenging therapeutic exercises after ischemic stroke tend to experience greater functional recovery, while if ignored or insufficiently treated, impairments may remain [4,5]. The dosage of motor skill practice correlates to the extent of motor recovery following a stroke [4]. In addition, the type of therapy delivered relative to patient’s impairment determines outcomes after therapy. For example, for those who have upper limb motor impairment, best therapeutic practice modifies the prescribed exercises as the patient’s symptoms evolve [5,6]. Regrettably, patients report their experiences of conventional repetitive stroke rehabilitation therapies as tedious and difficult to hold their interest, which conflicts with the fact that patient motivation is often required to obtain good clinical outcomes [7–10].
Rehabilitation doctors and medical staff, therefore, face a significant problem: how can they provide high intensity therapy in large quantities for upper limb impairments with this seemingly intrinsic motivational deficit? Especially problematic are patient’s therapeutic needs after their discharge from the hospital—their therapeutic needs still exist, but medical staff have substantially reduced access to the patient to provide targeted care. Given the difficulty of this problem, an insufficient percentage of patients regain the full functional potential of their upper limb after ischemic stroke [11]. This regrettable outcome motivates an ongoing search for new therapeutic approaches that provide acceptable (motivational, comfortable, and engaging) experiences, hence, effective therapy, especially at the patient’s home.
Use of commercial augmented reality devices has found recent application in stroke rehabilitation using existing expensive commercial headsets [4,6–17]. However, there are few studies that assay the acceptability of augmented reality gaming system–based patient rehabilitation after stroke [10,12,17–19], and then, only in a cursory fashion. For example, 30 patients recovering from stroke were surveyed for their opinions on game-based rehabilitation, and the researchers concluded that though games for patients recovering from stroke existed, they were primarily designed for efficacy, not entertainment [10]; they suggest investing in a single, affordable gaming platform for patient rehabilitation after stroke that also focuses on entertainment and provides diverse gaming content [10]. Augmented reality technology and an upper-limb assistive device were tested on 3 individuals recovering from stroke for 6 weeks, and the study reported that both the user and therapist believed that their augmented reality environment was user friendly due to the lightness of the assistive devices and the simplicity of set-up [18]. Finally, a study of 4 patients recovering from stroke who were exposed to several gaming platforms reported that manually adjusting the difficulty of games to provide a challenge and creating games with deeper story lines helped the patients stay motivated to perform their gaming exercises [17]. To the best of our knowledge, our case study is the first of its kind that analyzes the opinions of patients recovering from stroke regarding the problems of current augmented reality–specific game-based rehabilitation systems to provides insight into future designs of augmented reality game-based stroke rehabilitation systems. Augmented reality, provided by one of a variety of device designs, represents one such approach. Augmented reality projects a live camera view of a user’s environment and computer-generated objects with a variety of properties—movement and sound, typically. As an example, Pokémon Go, a smartphone-based augmented reality game, has had documented success sustaining the interest of users for extended periods of time while consistently increasing their physical activity [13], making augmented reality a prime candidate for facilitating otherwise tedious therapy.
Hypothesis
Since patient motivation often drives a larger dosage of rehabilitation therapy, hence, improved clinical outcomes [20,21], we hypothesized that augmented reality deployed on a relatively inexpensive and readily available platform—a smartphone—could provide a motivational, comfortable, and engaging rehabilitation experience. To test this hypothesis, we first developed a candidate rehabilitation game on a smartphone that could encourage a patient’s hand motions through use of simple visual cues with a custom-made app. We then asked patients with acute upper-motor stroke to use this system and report their experiences via a questionnaire that assayed the acceptability of the game in terms of motivation to continue to play, comfort, and engagement.
Methods
Overview
This acceptability study was conducted at Harborview Medical Center in Seattle, Washington from November 2018 to March 2019. Inpatients who were recovering from an acute ischemic stroke participated and provided consent. These patients had impaired strength as determined by physical and occupational therapists. To be included in the study, they had to have at least antigravity strength in deltoid or biceps muscles as well as the ability to perform internal and external shoulder rotations. All patients in this study had a Medical Research Council manual muscle score of 3 or 4 in the affected limb.
Intervention
We designed and built an augmented reality game using Unity (Unity Technologies) that is deployable on any modern smartphone with a camera (Table 1 and Figure 1). The game presents users with a view of an augmented reality dolphin swimming under the ocean with the task of capturing fish and feeding turtles, worn on the hand associated with the upper-limb deficit (Multimedia Appendix 1). To experience the game, patients wore an augmented reality headset, which did not obscure the camera mounted on the phone, and a custom device on their hand. We used two headsets—the Google Daydream headset, which required us to remove the front panel that held the phone in place, and the Merge augmented reality/virtual reality headset, which did not require any modification (Figure 1). The game also required users to place the hand associated with their motor deficits within a padded box that replaced their hand as seen in augmented reality with a dolphin (Figure 1). Finally, we required the user to look at a complex landscape through their headset while wearing the padded box and while playing the game. Instead of holding the phone, the headset supported the phone for the user. We built customized controllers with different interior sizes that changed the effective grip strength of the controller; this was important because our patients’ ability to hold the controllers varied. Viewing the complex landscape through the augmented reality system caused our software to create a seascape that contained a turtle, fish, and other underwater flora and fauna (Multimedia Appendix 1). Successful placement of the dolphin over a fish allowed the dolphin to capture the fish. Placement of the dolphin plus fish over the turtle allowed the user to feed the turtle, thereby winning points.
Notably, we used the TeamViewer (TeamViewer AG) app to project the screen view of the patient from the phone to a laptop, so we could see the patient’s view with, however, the complex landscape was also projected in the background, so we could check the viewer’s alignment with the landscape while they played (Figure 1).
Set-up of the game, to ensure that system function was verified, occurred prior to patients using the system. Patients followed verbal directions and instructions from study staff on how to use the system, facilitated by demonstration of the game using the TeamViewer app. Examples of directions included how to start the game, the actions required to pick up the fish, and how to colocate the dolphin plus fish with the turtle for point accumulation. Some patients required physical assistance to adjust the view of the environment. Examples of physical assistance included moving the patient’s chair or wheelchair closer or farther away from the images recognized by the camera (Figure 1).
[…]
[BLOG POST] 5 Smartphone Games That Encourage Wrist Rehabilitation
Posted by Kostas Pantremenos in Paretic Hand, REHABILITATION, Video Games/Exergames on October 11, 2019
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)
via 5 Smartphone Games That Encourage Wrist Rehabilitation | MedBridge Blog
TBI Rehabilitation 