Background: Stroke is increasingly one of the main causes of impairment and disability. Contextual and empirical evidence demonstrate that, mainly due to service delivery constraints, but also due to a move toward personalized health care in the comfort of patients’ homes, more stroke survivors undergo rehabilitation at home with minimal or no supervision. Due to this trend toward telerehabilitation, systems for stroke patient self-rehabilitation have become increasingly popular, with many solutions recently proposed based on technological advances in sensing, machine learning, and visualization. However, by targeting generic patient profiles, these systems often do not provide adequate rehabilitation service, as they are not tailored to specific patients’ needs.
Objective: Our objective was to review state-of-the-art home rehabilitation systems and discuss their effectiveness from a patient-centric perspective. We aimed to analyze engagement enhancement of self-rehabilitation systems, as well as motivation, to identify the challenges in technology uptake.
Methods: We performed a systematic literature search with 307,550 results. Then, through a narrative review, we selected 96 sources of existing home rehabilitation systems and we conducted a critical analysis. Based on the critical analysis, we formulated new criteria to be used when designing future solutions, addressing the need for increased patient involvement and individualism. We categorized the criteria based on (1) motivation, (2) acceptance, and (3) technological aspects affecting the incorporation of the technology in practice. We categorized all reviewed systems based on whether they successfully met each of the proposed criteria.
Results: The criteria we identified were nonintrusive, nonwearable, motivation and engagement enhancing, individualized, supporting daily activities, cost-effective, simple, and transferable. We also examined the motivation method, suitability for elderly patients, and intended use as supplementary criteria. Through the detailed literature review and comparative analysis, we found no system reported in the literature that addressed all the set criteria. Most systems successfully addressed a subset of the criteria, but none successfully addressed all set goals of the ideal self-rehabilitation system for home use.
Conclusions: We identified a gap in the state-of-the-art in telerehabilitation and propose a set of criteria for a novel patient-centric system to enhance patient engagement and motivation and deliver better self-rehabilitation commitment.
Stroke has become a global problem . One new case is reported every 2 seconds, and the number of stroke patients is predicted to increase by 59% over the next 20 years . In the United Kingdom alone, more than 100,000 stroke cases are reported annually , with impairment or disability affecting two-thirds of the 1.2 million stroke survivors . In the United Kingdom, only 77% of stroke survivors are taken directly to the stroke unit. Due to the high number of patients, in England, for example, the social care costs are almost £1.7 billion per annum. The social care cost varies with the age of the patient: the older the patient, the higher the cost. The cost for a person who has had a stroke was reported in 2017 to be around £22,000 per annum. Thus, cost is one of the main drives for service delivery practices. In that respect, early discharge units have been used due to better outcomes and greater success on rehabilitation. Early discharge units consist of specialized personnel who offer an intensive rehabilitation program to the patient. However, after this intensive program of relatively short duration, the patient is discharged and continues the rehabilitation at home. This is expected to reduce costs by £1600 over 5 years for every patient, according to a 2017 report .
Due to increasing pressure to discharge patients early from hospital , they rely increasingly on home rehabilitation to improve their condition after discharge. As a result, the need has been increasing for home rehabilitation systems that are not dependent on specialist or clinician operators [1,4,5] while providing service similar to a clinical environment. Technological advances in home rehabilitation have been mainly focused on motor control impairments due to their prevalence in the patient population (85% worldwide ).
Rehabilitation in a home environment can prove more efficient than that in a clinical environment, as the home environment supports patient empowerment through self-efficacy [6,7]. The presence of supportive family members and a familiarity with the space are significant contributors to motivation. Additionally, rehabilitation in cooperation or in competition with family members demonstrates higher level of engagement .
Though rehabilitation in the comfort of a patient’s home seems an attractive option, home environments have limitations that can affect the use of clinical devices. The most prevalent limitations are related to space and the lack of qualified personnel to operate devices. The number of occupants; the patient’s mobility, individual personality, and mood disorders following stroke; and sound insulation, home modification requirements, and cost [9,10] also contribute to limitations of home rehabilitation. Finally, different age groups react differently to technology and devices; for example, elderly survivors often do not engage with wearable devices or video games . As a result, stroke rehabilitation requires a person-centric approach that is suitable for the home environment and that does not require infrastructure change in the home.
The success of stroke rehabilitation depends heavily on personal commitment and effort. Recent studies, for example, on applied psychology in behavior change theories for stroke rehabilitation [12–14], do support that the self-esteem of the patient is limited after stroke. In addition, there is an extended sedentary period due to disability and, thus, different programs of activities are set to motivate the patients. Thus, the patient’s motivation and engagement have a critical impact on the success of any routine that is to be encouraged . This is especially critical for devices used at home, since patients are usually interacting with them alone without frequent checks. Indeed, if a device does not provide a high level of engagement or motivation enhancement, it is more likely to be abandoned within 90 days . Motivation levels depend on the individual, their achievements, and their needs at each given point in time. For example, once the patients achieve their physiotherapy exercise targets, they lose motivation for further practice. There are 3 main approaches to enhancing patients’ motivation: (1) goal-setting theory, (2) self-efficacy improvement theory, and (3) possible selves theory.
This approach has been proved effective for stroke survivors. According to the goal-setting theory, the patient’s motivation can be increased through setting small goals or targets. These need to be realistic, manageable, and well defined for the individual patient. However, they also need to be sufficiently challenging for the patient to be engaged [15,17–19]. Figure 1 presents the main components contributing to motivation enhancement based on the goal-setting theory.
The purported affective impact of virtual reality (VR) and active video gaming (AVG) systems is a key marketing strategy underlying their use in stroke rehabilitation, yet little is known as to how affective constructs are measured or linked to intervention outcomes. The purpose of this scoping review is to 1) explore how motivation, enjoyment, engagement, immersion and presence are measured or described in VR/AVG interventions for patients with stroke; 2) identify directional relationships between these constructs; and 3) evaluate their impact on motor learning outcomes.
A literature search was undertaken of VR/AVG interventional studies for adults post-stroke published in Medline, PEDro and CINAHL databases between 2007 and 2017. Following screening, reviewers used an iterative charting framework to extract data about construct measurement and description. A numerical and thematic analytical approach adhered to established scoping review guidelines.
One hundred fifty-five studies were included in the review. Although the majority (89%; N = 138) of studies described at least one of the five constructs within their text, construct measurement took place in only 32% (N = 50) of studies. The most frequently described construct was motivation (79%, N = 123) while the most frequently measured construct was enjoyment (27%, N = 42). A summative content analysis of the 50 studies in which a construct was measured revealed that constructs were described either as a rationale for the use of VR/AVGs in rehabilitation (76%, N = 38) or as an explanation for intervention results (56%, N = 29). 38 (76%) of the studies proposed relational links between two or more constructs and/or between any construct and motor learning. No study used statistical analyses to examine these links.
Results indicate a clear discrepancy between the theoretical importance of affective constructs within VR/AVG interventions and actual construct measurement. Standardized terminology and outcome measures are required to better understand how enjoyment, engagement, motivation, immersion and presence contribute individually or in interaction to VR/AVG intervention effectiveness.
An increasing evidence base supports the use of virtual reality (VR) and active video gaming (AVG) systems to promote motor learning in stroke rehabilitation [1, 2, 3, 4]. However, practical and logistical barriers to VR/AVG implementation in clinical sites have been well described [5, 6, 7]. To support their use, researchers and developers often emphasize the potential advantages of VR/AVG systems over conventional interventions, including that these technologies may enhance a patient’s affective experience in therapy for the purpose of facilitating recovery [8, 9, 10, 11]. Examining the role of affective factors for motor learning is an emerging area of emphasis in rehabilitation [2, 12, 13, 14, 15].
VR/AVG use may enhance patients’ motivation to participate in rehabilitation as well as their engagement in therapeutic tasks. Motivation encourages action toward a goal by eliciting and/or sustaining goal-directed behavior . Motivation can be intrinsic (derived from personal curiosity, importance or relevance of the goal) or extrinsic (elicited via external reward) . Engagement is a cognitive and affective quality or experience of a user during an activity . Many characteristics of VR/AVG play can contribute to user motivation and engagement, such as novelty, salient audiovisual graphics, interactivity, feedback, socialization, optimal challenge , extrinsic rewards, intrinsic curiosity or desire to improve in the game, goal-oriented tasks, and meaningful play .
Motivation and engagement are hypothesized to support motor learning either indirectly, through increased practice dosage leading to increased repetitive practice, or directly, via enhanced dopaminergic mechanisms influencing motor learning processes [15, 16]. Yet evidence is required to support these claims. A logical first step is to understand how these constructs are being measured within VR/AVG intervention studies. Several studies have used practice dosage or intensity as an indicator of motivation or engagement [19, 20, 21]. To the authors’ knowledge, few have specifically evaluated the indirect mechanistic pathway by correlating measurement of patient motivation or engagement in VR/AVGs with practice dosage or intensity. While participants in VR/AVG studies report higher motivation as compared to conventional interventions [22, 23, 24], conclusions regarding the relationship between motivation and intervention outcomes are limited by lack of consistency and rigour in measurement, including the use of instruments with poor psychometric properties [22, 23].
The body of research exploring the direct effects of engagement or motivation on motor learning is still in its infancy. Lohse et al.  were the first to evaluate whether a more audiovisually enriched as compared to more sterile version of a novel AVG task contributed to skill acquisition and retention in typically developing young adults, finding that participants who played under the enriching condition had greater generalized learning and complex skill retention. Self-reported engagement (User Engagement Scale; UES) was higher in the enriched group, but the only difference in self-reported motivation was in the Effort subscale of the Intrinsic Motivation Inventory (IMI), where the enriched group reported less effort as compared to the sterile group. The authors did not find a significant correlation between engagement, motivation and retention scores. A follow-up study using electroencephalography did not replicate the finding that the more enriched practice condition enhanced learning, it did show that more engaged learners had increased information processing, as measured by reduced attentional reserve .
Enjoyment, defined as ‘the state or process of taking pleasure in something’ , has less frequently been the subject of study in motor learning research, but has become popular as a way of describing patient interaction with VR/AVGs. Enjoyment may be hypothesized to be a precursor to both motivation and engagement. Given that the prevailing marketing of VR/AVGs is that they are ‘fun’ and ‘enjoyable’ [1, 3, 14, 27], it is important to evaluate its measurement in the context of other constructs.
Motivation, engagement and enjoyment in VR/AVGs may be influenced by the additional constructs of immersion and presence. Immersion is defined as “the extent to which the VR system succeeds in delivering an environment which refocuses a user’s sensations from the real world to a virtual world” [13, 28]. Immersion is considered as an objective construct referring to how the computational properties of the technology can deliver an illusion of reality through hardware, software, viewing displays and tracking capabilities [29, 30]. A recent systematic review  could not conclusively state effect of immersion on user performance. Immersion is distinct from presence, defined as the “psychological product of technological immersion” . Presence is influenced by many factors, including the characteristics of the user, the VR/AVG task, and the VR/AVG system . While presence is thought to be related to enhanced motivation and performance , relationships between this and other constructs of interest require exploration. Table 1 outlines definitions of constructs of interest to this scoping review.
Motivation encourages action toward a goal by eliciting and/or sustaining goal-directed behavior.
The purpose of this scoping review is to explore the impact of these affective constructs on motor learning after stroke. This greater understanding will enhance the clinical rationale for VR/AVG use and inform directions for subsequent research. Specifically, our objectives were to:
Describe how VR/AVG studies measure or report client enjoyment, motivation, engagement, immersion and presence.
Evaluate the extent to which motivation, enjoyment, engagement, immersion, and presence impact motor learning.
Propose directional relationships between enjoyment, motivation, engagement, immersion, presence and motor learning.
We present ongoing work to develop a virtual reality environment for the cognitive rehabilitation of patients as a part of their recovery from a stroke. A stroke causes damage to the brain and problem solving, memory and task sequencing are commonly affected. The brain can recover to some extent, however, and stroke patients have to relearn to carry out activities of daily learning. We have created an application called VIRTUE to enable such activities to be practiced using immersive virtual reality. Gamification techniques enhance the motivation of patients such as by making the level of difficulty of a task increase over time. The design and implementation of VIRTUE is presented together with the results of a small acceptability study.
Rehabilitation encompasses a wide variety of activities aimed at reducing the impact of injuries and disabilities by applying different exercises. Frequently, such exercises are carried out at home as a repetition of the same movements or tasks to achieve both motor learning and the necessary cortical changes. Although this increases the patients’ available time for rehabilitation, it may also have some unpleasant side effects. That occurs because carrying out repetitive exercises in a more isolated environment may result in a boring activity that leads patients to give up their rehabilitation. Therefore, patients’ motivation should be considered an essential feature while designing rehabilitation exercises. In this paper, we present how we have faced this need by exploiting novel technology to guide patients in their rehabilitation process. It includes a game crafted to make recovery funny and useful, at the same time. The game and the use we made of the specific hardware follow the recommendations and good practices provided by medical experts.
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OBJECTIVE:This review evaluates the use of virtual reality (VR) tools in cognitive rehabilitation of stroke-affected individuals.
METHODS:Studies performed between 2010 and 2017 that fulfilled inclusion criteria were selected from PubMed, Scopus, Cochrane, and Web of Sciences databases. The search combined the terms “VR,” “rehabilitation,” and “stroke.”
RESULTS:Stroke patients experienced significant improvement in many cognitive domains (such as executive and visual-spatial abilities and speech, attention, and memory skills) after the use of VR training.
CONCLUSIONS:Rehabilitation using new VR tools could positively affect stroke patient cognitive outcomes by boosting motivation and participation.
Lack of motivation during physical rehabilitation is a very common problem that worsens the efficacy of rehabilitation, decreasing the recovery rates of the patient. We suggest a gamified upper-limb rehabilitation that incorporates adaptive gameplay and difficulty so as to overcome that issue, emerging as a support tool for physical therapy professionals. The presence of difficulty adjustment in the game allows a higher motivation level for the patients by preserving the trade off between keeping the difficulty low enough to avoid frustration, but high enough to promote motivation and engagement. This rehabilitation game is a home-based system that allows the patient to exercise at home, due to its Kinect-based portable setup. The game aims to increase the motivation of the patients and thus the speed of their recovery. To accomplish that goal, it is key to potentiate a full immersion into the therapeutic activity. Thus gamification elements, gameplay design and adaptive difficulty are explored and incorporated into the concept.
People with neurological injuries such as stroke should exercise frequently and intensely to regain their motor abilities, but are generally hindered by lack of motivation. One way to increase motivation in rehabilitation is through competitive exercises, but such exercises have only been tested in single brief sessions and usually did not adapt difficulty to the patient’s abilities.
We designed a competitive arm rehabilitation game for two players that dynamically adapts its difficulty to both players’ abilities. This game was evaluated by two participant groups: 15 participants with chronic arm impairment who exercised at home with an unimpaired friend or relative, and 20 participants in the acute or subacute phase of stroke who exercised in pairs (10 pairs) at a rehabilitation clinic. All participants first played the game against their human opponent for 3 sessions, then played alone (against a computer opponent) in the final, fourth session. In all sessions, participants’ subjective experiences were assessed with the Intrinsic Motivation Inventory questionnaire while exercise intensity was measured using inertial sensors built into the rehabilitation device. After the fourth session, a final brief questionnaire was used to compare competition and exercising alone.
Participants who played against an unimpaired friend or relative at home tended to prefer competition (only 1 preferred exercising alone), and exhibited higher enjoyment and exercise intensity when competing (first three sessions) than when exercising alone (last session).
Participants who played against each other in the clinic, however, did not exhibit significant differences between competition and exercising alone. For both groups, there was no difference in enjoyment or exercise intensity between the first three sessions, indicating no negative effects of habituation or novelty.
Competitive exercises have high potential for unsupervised home rehabilitation, as they improve enjoyment and exercise intensity compared to exercising alone. Such exercises could thus improve rehabilitation outcome, but this needs to be tested in long-term clinical trials. It is not clear why participants who competed against each other at the clinic did not exhibit any advantages of competition, and further studies are needed to determine how different factors (environment, nature of opponent etc.) influence patients’ experiences with competitive exercises.
The study is not a clinical trial. While human subjects are involved, they do not participate in a full rehabilitation intervention, and no health outcomes are examined.
Electronic supplementary material
The online version of this article (10.1186/s12984-017-0336-9) contains supplementary material, which is available to authorized users.
Stroke is a leading cause of disability, with 795,000 new or recurrent strokes per year in the United States alone . 88% of survivors experience motor function impairment and thus require rehabilitation to regain their movement abilities . However, even top hospitals devote only an hour per day to motor rehabilitation , and exercise intensity is usually too low for optimal rehabilitation outcome . Patients are thus expected to exercise independently at home after leaving the clinic to fully regain their abilities, but frequently do not exercise frequently or intensely enough. For example, one study found that only 30% of unsupervised patients comply with prescribed home rehabilitation regimens . Another home rehabilitation study found that patients average around 1.5 h of exercise per week , while clinical studies involve at least 3 h of exercise per week [7, 8]. To improve home rehabilitation, it is therefore critical to increase the frequency and intensity of exercise.
One key reason for poor compliance in home rehabilitation is lack of motivation, which is an important predictor of rehabilitation outcome [9, 10]. While the definition of motivation in rehabilitation is blurry, it is generally agreed to involve a willingness to actively engage in exercise [11, 12]. To improve engagement, researchers have thus developed numerous rehabilitation games that try to both ensure high enjoyment (using, e.g., meaningful goals, in-game rewards and entertaining graphics [12–15]) and provide an appropriate exercise intensity via automated difficulty adaptation [12, 14, 16]. The games are controlled using motion tracking hardware such as the Microsoft Kinect or even with rehabilitation robots that provide limb support in addition to motion tracking. However, recent reviews have emphasized that such games are not yet sufficiently engaging for all patients [17, 18]. Therefore, additional rehabilitation game development and validation is necessary to improve patient engagement.[…]
Fig. 1 The Bimeo arm rehabilitation system in the wrist and forearm training configuration. Inertial sensors are attached to the upper arm, attached to the forearm, and integrated in the sphere that supports the hand
‘Executive dysfunction‘ is not, perhaps, a particularly well known term, but the effects of brain injury that it covers are very common indeed. It is used to collectively describe impairment in the ‘executive functions’ – the key cognitive, emotional and behavioural skills that are used to navigate through life, especially when undertaking activities and interacting with others.
Although executive dysfunction is a common problem among many brain injury survivors, it is most commonly experienced following an injury to the frontal lobe.
The importance of executive functions is shown by the difficulties caused when they don’t work properly and someone has problems with executive dysfunction. Since the executive functions are involved in even the most routine activities, frontal injuries leading to executive dysfunction can lead to problems in many aspects of life.
Here we list the most common effects of executive dysfunction, with some examples of common issues that brain injury survivors can face:
Difficulties with motivation and organisation
Loss of ‘get up and go’, which can be mistaken for laziness
Problems with thinking ahead and carrying out the sequence of steps needed to complete a task
Difficulty in evaluating the result of actions and reduced ability to change behaviour or switch between tasks if needed
Poor problem solving
Finding it hard to anticipate consequences
Decreased ability to make accurate judgements or find solutions if things are going wrong
Acting too quickly and impulsively without fully thinking through the consequences, for example, spending more money than can be afforded
Difficulty in controlling emotions which may lead to outbursts of emotion such as anger or crying
Rapid mood changes may occur, for example, switching from happiness to sadness for no apparent reason
Difficulties in social situations
Reduced ability to engage in social interactions
Finding it hard to initiate, participate in, or pay attention to conversations
Poor judgement in social situations, which may lead to saying or doing inappropriate things
Finding it harder to concentrate
Difficulty with learning new information
Decreased memory for past or current events, which may lead to disorientation
Find out more
If you or someone you care for is affected by executive dysfunction, it is important to seek support. Speak to your doctor about your symptoms, and ask about referral to specialist services such as counselling, neuropsychology and rehabilitation.
The use of computers in the e-Health domain is becoming increasingly common, since technology is present in most aspects of our lives. In the rehabilitation field in particular, some additional issues requiring the use of computer-assisted therapies arise. On the one hand, there is a scarce availability of rehabilitation specialists and centers to satisfy the growing demand of their services. This problem gets even magnified because of the ageing population. On the other hand, the huge opportunities that the new interaction devices can bring to rehabilitation smooth the path towards novel therapies.
Nevertheless, even if a proper rehabilitation therapy is prescribed, it can fail because of the patient´s lack of motivation There are assorted motivation theories available in the literature to address this demotivation of patients. Unfortunately, there is no model or guide to put those theories into practice in computer-assisted rehabilitation. This paper is aimed at filling this gap by providing a model, namely Influence Awareness, to support the specification of motivation aspects in those applications used in computer-assisted rehabilitation.
Furthermore, some guidelines are also provided, so that the designer can get some extra guidance on some heuristics about how to design motivation. The integration of motivation design into a model-based development process is presented by showing how this motivation model is integrated into a task model. Finally, to better illustrate our approach a case study based on a collaborative e-Health system is also included.
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Playing virtual reality games could be as effective as adding extra physical therapy sessions to a stroke patient’s rehab regimen, according to researchers.
“It is not a question of choosing one thing over the other, rather of having different training alternatives to provide variation,” says Iris Brunner, author of a study, published recently in Neurology, that explored a variety of medical uses for virtual reality.
“Virtual reality cannot replace physical therapy. But it can be experienced as a game, motivating patients to do an extra treatment session,” adds Brunner, associate professor with the University of Aarhus and Hammel Neurocenter, in Denmark.
Brunner and her team’s study included 120 stroke patients with mild to severe hand weakness, all of whom were randomly assigned to add 16 hour-long therapy sessions to their routine rehabilitation over a month. One group performed physical therapy, while the other group played a virtual reality game called YouGrabber, notes a media release from HealthDay.
In the game, Brunner explains, “the patients wear gloves with sensors, and their movements are tracked by an infrared camera and transferred to a virtual arm on screen.”
“In different scenarios, they can grasp objects that come toward them or pick carrots. In other games, patients steer a plane or a car with their movement. The therapist chooses the movements to be trained and the level of difficulty.”
Fifty patients in the physical therapy group and 52 in the virtual reality group completed the study and were evaluated after 3 months.
The researchers found no difference between the two groups with regard to the improvement in their hand and arm function.
“Patients who started out with moderately to mildly impaired arm and hand motor function achieved, on average, a level of good motor function,” Brunner states, while those with severe weakness were able to use their arms to make movements.
Patients with severe hand weakness appreciated how even small movements translated to the virtual arms on screen, she adds. And even the older patients liked the virtual reality game, she notes, possibly because the graphics are simpler than those in commercial video games.
Brunner concludes by noting that larger studies are needed to understand the potential value of virtual reality as a stroke recovery treatment.