Posts Tagged Serious games

[ARTICLE] Serious games for upper limb rehabilitation after stroke: a meta-analysis – Full Text

Abstract

Background

Approximately two thirds of stroke survivors maintain upper limb (UL) impairments and few among them attain complete UL recovery 6 months after stroke. Technological progress and gamification of interventions aim for better outcomes and constitute opportunities in self- and tele-rehabilitation.

Objectives

Our objective was to assess the efficacy of serious games, implemented on diverse technological systems, targeting UL recovery after stroke. In addition, we investigated whether adherence to neurorehabilitation principles influenced efficacy of games specifically designed for rehabilitation, regardless of the device used.

Method

This systematic review was conducted according to PRISMA guidelines (PROSPERO registration number: 156589). Two independent reviewers searched PubMed, EMBASE, SCOPUS and Cochrane Central Register of Controlled Trials for eligible randomized controlled trials (PEDro score ≥ 5). Meta-analysis, using a random effects model, was performed to compare effects of interventions using serious games, to conventional treatment, for UL rehabilitation in adult stroke patients. In addition, we conducted subgroup analysis, according to adherence of included studies to a consolidated set of 11 neurorehabilitation principles.

Results

Meta-analysis of 42 trials, including 1760 participants, showed better improvements in favor of interventions using serious games when compared to conventional therapies, regarding UL function (SMD = 0.47; 95% CI = 0.24 to 0.70; P < 0.0001), activity (SMD = 0.25; 95% CI = 0.05 to 0.46; P = 0.02) and participation (SMD = 0.66; 95% CI = 0.29 to 1.03; P = 0.0005). Additionally, long term effect retention was observed for UL function (SMD = 0.42; 95% CI = 0.05 to 0.79; P = 0.03). Interventions using serious games that complied with at least 8 neurorehabilitation principles showed better overall effects. Although heterogeneity levels remained moderate, results were little affected by changes in methods or outliers indicating robustness.

Conclusion

This meta-analysis showed that rehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components. Irrespective of the technological device used, higher adherence to a consolidated set of neurorehabilitation principles enhances efficacy of serious games. Future development of stroke-specific rehabilitation interventions should further take into consideration the consolidated set of neurorehabilitation principles.

Background

Each year more than 1 million Europeans suffer from stroke and approximately two-thirds of survivors maintain upper limb (UL) paresis [1]. This number is expected to rise by 35% in upcoming years [2] leading to additional rehabilitation needs. To this date, few people attain complete UL recovery 6 months after stroke [3]. New interventions targeting the UL aim for better outcomes in activities of daily living (ADL), functional independence and quality of life. Alongside conventional therapies, recent developments offer possibilities in self- and tele-rehabilitation [4] which could help manage, cost-efficiently [5], increasing rehabilitation demands.

Technological improvements in robot assisted therapy (RAT) and virtual reality (VR) systems (VRS) enhance patient care and facilitate therapist assistance during UL rehabilitation [67]. First, RAT promotes the use of the affected limb, intensifies rehabilitation through task repetition and offers task-specific practice [7]. Effectiveness of RAT is established for UL rehabilitation after stroke [89]. Secondly, VRS provide augmented feedback, preserve motivation and are becoming cost-efficient [5]. Recent meta-analyses suggest a superior effect of VR-based interventions compared to conventional treatment on UL function and activity after stroke, especially if developed for this specific purpose [1012]. Authors attributed these findings to the fact that VRS specifically developed for rehabilitation, as opposed to commercial video-games (CVG), fulfil numerous neurorehabilitation principles.

Typically, a common denominator of VRS and RAT is playful interventions by means of serious games [1314]. A serious game is defined as a game that has education or rehabilitation as primary goal. These games combine entertainment, attentional engagement and problem solving to challenge function and performance [1516]. Moreover, they comply with several motor relearning principles that constitute the basis of effective interventions in neurorehabilitation [1116]. For example, some devices adapt game difficulty to stimulate recovery and maintain motivation [15]. Others incorporate functional tasks mimicking ADL in virtual environments and provide performance feedback during and/or after task completion [17]. Characteristics of serious games differ depending on targeted rehabilitation purposes and technical specificities of the system they are implemented on.

Previous work on the efficacy of VR-based interventions indicated that serious games may enhance UL recovery after stroke [111218]. However, why such interventions, specifically developed for rehabilitation purposes and implemented on various types of devices (such as robots, smartphones, tablets, motion capture systems, etc.), may constitute effective therapies for UL rehabilitation after stroke needs to be further investigated. Recent theoretical research proposed consolidation of commonly acknowledged neurorehabilitation principles [16]. Usually, serious games comply with several of these principles which creates an opportunity to evaluate clinical applicability of the consolidated set of principles. To this day, it remains unclear whether higher adherence to this consolidated set of neurorehabilitation principles enhances efficacy of interventions. In addition, it is not well known whether adherence to specific principles influences efficacy. Finally, rehabilitation effects on participation outcomes remain relatively unexplored. In this context, efficacy of interventions should be addressed in terms of all components of the World Health Organization’s International Classification of Function, Disability, and Health (ICF-WHO) model [19].

The main objective of this systematic review and meta-analysis was to address the following question in PICOS form: in adults after stroke (P), do serious games, implemented on various technological systems (I), show better efficacy than conventional treatment (C), to rehabilitate UL function and activity, and patient’s participation (O)? A secondary objective was to assess whether higher adherence to a consolidated set of neurorehabilitation principles enhances efficacy of games specifically designed for rehabilitation, irrespective of the technological device used.[…]

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[Abstract] Proteo: A Framework for Serious Games in Tele-rehabilitation[v1] – Preprints

Abstract

Background: Tele-rehabilitation has grown significantly in the past years, especially in 2020 when it has been a crucial tool for supporting patients during the COVID-19 pandemic. Within the context of tele-rehabilitation, serious games have a significant role. However, realizing software for serious games capable of responding to the variety of user needs is resource demanding.

Methods: we present Proteo, a modular framework for developing serious games from scratch, but with the ability of providing a high-level interface for game customization by therapists and researchers. We also present two serious game implementation examples with analysis of end user’s and therapists/researchers’ satisfaction.

Results: by involving a group of 11 specialized therapists and 9 end users we analyzed the Proteo user’s satisfaction. We found that therapists and end users scored high level of involvement, and the therapists scored also high level of suitability. More in depth, both groups showed significant differences between positive and negative feeling, with positive feeling scoring higher than negative ones. Finally, concerning Users’ level of suitability the condition of successfulness of the system, ability to control, clarity and helpfulness were reported as high while the difficulty of the system and the difficulty of the task were reported as low.

Conclusions: the proposed framework is a step forward in providing a comprehensive open-source, modular framework, to develop serious games for tele-rehabilitation. Proteo is distributed with a MIT license and available to researchers on GitHub and has been well accepted by the users we involved in the evaluation tests.

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[Abstract] Effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke – a systematic review and meta-analysis protocol

Abstract

Objective: 

To evaluate and summarize the level of evidence for the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke.

Introduction: 

A game-based intervention is a valuable therapeutic tool for incorporating principles of motor learning and neuroplasticity in the rehabilitation of upper limb function post-stroke. Most of the existing reviews on game-based rehabilitation are focused on the chronic phase of stroke. However, as maximum upper limb motor recovery occurs in the first six months after stroke, further exploration of the effects of game-based rehabilitation in this phase is necessary.

Inclusion criteria: 

We will include randomized clinical trials assessing the immediate, short-term, and long-term effects of game-based rehabilitation on upper limb function in adults within the first six months following stroke.

Methods: 

The systematic review will follow the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) checklist and JBI methodology for systematic reviews of effectiveness. A database-specific search strategy will be used in CINAHL, PubMed, Scopus, Web of Science, ProQuest, PEDro, OT Seeker, and Ovid MEDLINE to identify studies in the English language with no date limit. Two reviewers will independently screen, extract data, and assess risk of bias of the eligible studies. Meta-analysis and publication bias evaluation will be done when adequate data are available. If a meta-analysis is precluded, then a narrative synthesis will be done. The Grading of Recommendations Assessment Development and Evaluation (GRADE) criteria will be used to assess the certainty of evidence for the outcome measures of interest.

Systematic review registration number: PROSPERO CRD42020190100

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[ARTICLE] A usability study in patients with stroke using MERLIN, a robotic system based on serious games for upper limb rehabilitation in the home setting – Full Text

Abstract

Background

Neuroscience and neurotechnology are transforming stroke rehabilitation. Robotic devices, in addition to telerehabilitation, are increasingly being used to train the upper limbs after stroke, and their use at home allows us to extend institutional rehabilitation by increasing and prolonging therapy. The aim of this study is to assess the usability of the MERLIN robotic system based on serious games for upper limb rehabilitation in people with stroke in the home environment.

Methods

9 participants with a stroke in three different stages of recovery (subacute, short-term chronic and long-term chronic) with impaired arm/hand function, were recruited to use the MERLIN system for 3 weeks: 1 week training at the Maimonides Biomedical Research Institute of Cordoba (IMIBIC), and 2 weeks at the patients’ homes. To evaluate usability, the System Usability Scale (SUS), Adapted Intrinsic Motivation Inventory (IMI), Quebec User Evaluation of Satisfaction with assistive Technology (QUEST), and the ArmAssist Usability Assessment Questionnaire were used in the post-intervention. Clinical outcomes for upper limb motor function were assessed pre- and post-intervention.

Results

9 patients participated in and completed the study. The usability assessment reported a high level of satisfaction: mean SUS score 71.94 % (SD = 16.38), mean QUEST scale 3.81 (SD = 0.38), and mean Adapted IMI score 6.12 (SD = 1.36). The results of the ArmAssist Questionnaire showed an average of 6 out of 7, which indicates that MERLIN is extremely intuitive, easy to learn and easy to use. Regarding clinical assessment, the Fugl-Meyer scores showed moderate improvements from pre- to post-intervention in the total score of motor function (p = 0.002). There were no significant changes in the Modified Ashworth scale outcomes (p = 0.169).

Conclusions

This usability study indicates that home-based rehabilitation for upper limbs with the MERLIN system is safe, useful, feasible and motivating. Telerehabilitation constitutes a major step forward in the use of intensive rehabilitation at home.

Background

Strokes are among the leading causes of death, physical disability and economic burden worldwide [12]. The prevalence of people living with the effects of stroke has increased over the last few years, thus creating a higher demand for rehabilitation services [3]. The paralysis of the upper limbs is a common impairment after strokes, and only 10–20% of patients recover completely [45]: for these patients, the main aim of arm rehabilitation is to recover lost functions [6]. Nowadays, the key aspects to make rehabilitation effective for people with stroke are considered to be intensity, repetition and using suitably challenging and function-oriented activities [7,8,9]. However, the increase in the number of people affected and the current limitation of health resources make it very difficult to provide services using a traditional approach.

Continuous advances in neuroscience and neurotechnology are transforming stroke rehabilitation [10]. At a time when the rehabilitation services resources are unable to meet the demand, robot-assisted rehabilitation and home-based telerehabilitation are gaining greater acceptance [11]. Robot-based neurorehabilitation systems provide a solution to increase the number of movements, involve safe, intensive rehabilitation exercises [1213] and have the advantage that the precise movements of the robot are able to measure the patients’ movements objectively [1415]. On the other hand, home-based telerehabilitation allows us to extend institutional rehabilitation by increasing and prolonging the therapy [16]. What is more, the combination of game-based telerehabilitation and robotic systems creates a motivating, engaging environment for patients [17]. The enjoyment patients derive from playing these so called ‘serious games’, designed specifically for the rehabilitation tasks, can greatly increase the quality and quantity of the therapy delivered [18].

MERLIN is a robotic system based on serious games for the upper limb tele rehabilitation in patients with a stroke. It is presented as an affordable and easy to use solution to allow the patient to carry out an intensive rehabilitation at home, with a continuous remote monitoring and communication with the therapist. The system is composed of an upper-limb rehabilitation robot and a software platform which guides and measures the patient’s movements and allows physicians to customize the therapeutic plan and to monitor the patients’ evolution.

The purpose of this manuscript is to present the usability validation of MERLIN system. In this study, we evaluate the ease to use, consistency and acceptance of the system have been evaluated. The research carried out also aims to demonstrate the feasibility of including the robotic therapy as a complement to a regular daily rehabilitation program.

Methods

Participants

In order to detect most problems of usability which can affect a product, Jakob Nielsen’s theory [19] regarding the sufficient number of users to evaluate a system is widely accepted. According to Nielsen, between three and five users can identify 85% of the most relevant usability problems. In this case, due to the heterogeneity of the study population, it was decided to recruit 12 patients at different stages of post-stroke upper limb recovery, in order to test as many system features as possible.

Participants were recruited at the Reina Sofía University Hospital in Cordoba, Spain. The participants were divided in three different groups, depending on their stage of recovery: subacute (2–6 months of recovery of stroke), short-term chronic (6–12 months) and long-term chronic (over 12 months). Four patients were recruited from each stage. The inclusion criteria to participate in the study were: subjects over 18 with upper limb hemiparesis after stroke, unilateral paresis and cognitive ability to understand, accept and actively participate in the usability study. Having Wi-Fi at home and a table measuring 110 × 68 cm on which the MERLIN system can be set up was considered also a requirement to participate in the study. Patients who presented bilateral motor deficit, severe spasticity, psychiatric illness, and/or cognitive impairment were excluded.

All the subjects were duly informed about the study and all of them gave their written consent before the first session.

Study design

This interventional study is an open label trial with a single group and a longitudinal design. Each patient used the MERLIN system for 3 weeks: 1 week training at the IMIBIC (Maimonides Biomedical Research Institute in Córdoba, Spain) with the supervision of a physiotherapist, 1 week at the patient’s home with similar supervision and 1 week at patient’s home on their own with remote support and supervision of a physiotherapist to organize the rehabilitation sessions.

Arm and hand functions were evaluated at baseline (on day 1 before starting the training), and on the last day. The usability of the system and the participants’ motivation was evaluated on the last day using different validated scales, as explained below.

MERLIN unactuated robotic telerehabilitation system

The MERLIN system has been developed to bring neurorehabilitation to the post-stroke patients’ homes with the aim of providing daily, intensive, motivating and patient-tailored rehabilitation, with the indirect supervision of the therapist [20]. The system is composed of ArmAssist (AA), a cost-effective robotic system based on serious games developed by TECNALIA, and the Antari Home Care platform [21] to supervise, organize and customize the patients’ daily training remotely, which has been developed by GMV [22]. The AA system is a modular solution which includes an affordable, portable robotic device for a complete upper limb rehabilitation, and a software platform based on serious games to motivate the patients and assess their training [18].

In the MERLIN system, the non-actuated version of the AA robotic device has been used to ensure a safe use in the home environment when continuous supervision is not feasible. The AA device includes several sensors to measure the patient’s active self-directed active movements during the games, which are performed on a normal table to control the games (see Fig. 1). The device can be easily fastened on the forearm, and allows natural movements with low resistance. The position and orientation of the robot are calculated using the information from the camera, which reads the QR codes on the mat below, and the encoders included on the wheels. Wrist angle, hand grasping force and vertical arm force are calculated by a potentiometer, and two Force Sensing Resistors (FSR) and a load cell are included on the hand module and arm support, respectively. The key movements that can be measured are: three types of movements over the table, horizontal shoulder abduction-adduction, flexion–extension in the elbow (vertical force), wrist prono-supination movements and hand opening and closing [23]. This version of the system is aimed at patients who can actively carry out the movements and is thus more appropriate for patients who have mild or moderate motor impairment according to the Fugl-Meyer scale, who are more suited to continuing the therapy at home. The movements are used to interact with the implemented serious games on the software, which are divided into different levels depending on the patients’ stage of recovery and cognitive capabilities. The games include assessment and training [24] and they were co-designed by patients and physiotherapists [25]. 7 training games are available, such as choosing letters to make a word, discovering pairs, solitaire or doing a puzzle, for example. Additionally, the option of using some online games is also available. This option is recommended for patients with good movement control and cognitive capabilities. The games can be configured for only some movements or a combination of different ones. The exercises involve extending the user’s range of exercises beyond their normal threshold, which has been previously set by the assessment games, and can be modified when necessary, i.e. when motor improvement is detected by the physiotherapist. The games have been adapted to for the target group taking into account any possible cognitive or visual problems [26].

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Fig.1

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[ARTICLE] Serious Games for Stroke Telerehabilitation of Upper Limb – A Review for Future Research – Full Text

Abstract

Maintaining appropriate home rehabilitation programs after stroke, with proper adherence and remote monitoring is a challenging task.  Virtual reality (VR) – based serious games could be a strategy used in telerehabilitation (TR) to engage patients in an enjoyable and therapeutic approach. The aim of this review was to analyze the background and quality of clinical research on this matter to guide future research. The review was based on research material obtained from PubMed and Cochrane up to April 2020 using the PRISMA approach.  The use of VR serious games has shown evidence of efficacy on upper limb TR after stroke, but the evidence strength is still low due to a limited number of randomized controlled trials (RCT), a small number of participants involved, and heterogeneous samples. Although this is a promising strategy to complement conventional rehabilitation, further investigation is needed to strengthen the evidence of effectiveness and support the dissemination of the developed solutions.

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[Abstract + References] Novel Technologies in Upper Extremity Rehabilitation

Abstract

Structured and sufficient training is a key factor for successful fitting of an upper limb prosthesis. This is especially true for more advanced myoelectric control strategies, or for individuals with comorbidities that require additional treatment. With advances in technology, not only have the control strategies become more complex, but also possibilities for more tailored rehabilitation have increased. Novel rehabilitation technologies include virtual and augmented reality systems, as well as training systems relying on computers and smartphone apps. These technologies can be used within the clinical setting, enable telerehabilitation, and/or can support unsupervised home training. While most experts agree that novel rehabilitation technologies can be a good supplement for conventional therapy, one of the greatest challenges is to transfer the progress achieved in the technology-assisted realm into real-world situations and actual prosthetic function.

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[Abstract + References] Virtual Reality Games for Stroke Rehabilitation: A Feasibility Study – Conference paper

Abstract

The success of stroke rehabilitation therapy is highly associated with patient cooperation. However, the repetitive nature of conventional therapies can frustrate patients and decrease their discipline in working out the physical therapy program. Serious games have shown promising outcomes when applied to tasks that require human engagement. This research focuses on sharing experiences and lessons learned from designing serious games using VR technology in cooperation with medical experts including rehab physicians, occupational therapists and physiotherapists to identify requirements and to evaluate the game before applying with stroke patients. The game has the objective to create an immersive environment that encourages the patient to exercise for recovery from stroke-induced disabilities. It is delicately designed to fit the stroke sufferers in Thailand, meanwhile, to integrate proper clinical physio therapeutic patterns based on the conventional therapy. Game design challenges for stroke patients and our solutions applied in the games were described. Our results of the preliminary field test revealed positive feedback on enjoyment and game features from physicians and physiotherapists. Finally, technical issues and suggestions for improvement were collected to adjust the game for the clinical trial with stroke patients in the next phase.

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[Abstract] At-Home Self-Administration of an Immersive Virtual Reality Therapeutic Game for Post-Stroke Upper Limb Rehabilitation – Full Text PDF

Abstract

After a stroke, it is common to experience weakness or paralysis on one side of the body, including difficulty incorporating an affected upper extremity in activities of daily living. Virtual reality and video games that encourage task-oriented movement have been recognized as a valid clinical approach for providing stroke survivors with additional therapy. However, there have been few, if any, reports that examine the use of immersive virtual reality in the home for this purpose. Here, we describe a case study of a stroke survivor utilizing a therapeutic gaming system in the home over the course of several months. The digital therapeutic, CogniviveVR, utilizes head-mounted display-based virtual reality to provide patients with an immersive world where therapeutic tasks can be generated and dynamically self-adapted within a patient’s peripersonal space. The therapy was found to be feasible, well-tolerated, and engaging, with the study participant self-administering therapy approximately half an hour per day, 5-6 times a week over the course of eight weeks. Analysis of 3D motion data collected during sessions showed significant improvements in movement smoothness during performance of game tasks. After this pilot study, the system was successfully adapted to run on a stand-alone virtual reality headset. This has substantially reduced system setup requirements and will enable additional home-based studies to be conducted without the need for a study staff member to visit patients? homes to verify installation.

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[PhD Thesis] The Design Of Exergaming Systems For Autonomous Rehabilitation

A PhD thesis by Michele Pirovano (Politecnico di Milano, Italy), studying the feasibility of at-home rehabilitation using exergames for stroke patients. It includes the results of a 3-months pilot test using an original exergaming system developed by the author.

Download the thesis for free at http://www.michelepirovano.com/pdf/MichelePirovano_Thesis_Final_2015_01_09.pdf

via PhD Thesis: The Design Of Exergaming Systems For Autonomous Rehabilitation – Gabriele Ferri’s research blog

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[ARTICLE] An interactive and low-cost full body rehabilitation framework based on 3D immersive serious games – Full Text

Highlights

  • Generation of customizable 3D immersive serious games.
  • An interactive and low-cost full body rehabilitation framework.
  • Integration of a Head Mounted Display, a Time-of-Flight and an infrared camera.
  • A Gated Recurrent Unit Recurrent Neural Network (GRU-RNN) reference model.

Abstract

Strokes, surgeries, or degenerative diseases can impair motor abilities and balance. Long-term rehabilitation is often the only way to recover, as completely as possible, these lost skills. To be effective, this type of rehabilitation should follow three main rules. First, rehabilitation exercises should be able to keep patient’s motivation high. Second, each exercise should be customizable depending on patient’s needs. Third, patient’s performance should be evaluated objectively, i.e., by measuring patient’s movements with respect to an optimal reference model. To meet the just reported requirements, in this paper, an interactive and low-cost full body rehabilitation framework for the generation of 3D immersive serious games is proposed. The framework combines two Natural User Interfaces (NUIs), for hand and body modeling, respectively, and a Head Mounted Display (HMD) to provide the patient with an interactive and highly defined Virtual Environment (VE) for playing with stimulating rehabilitation exercises. The paper presents the overall architecture of the framework, including the environment for the generation of the pilot serious games and the main features of the used hand and body models. The effectiveness of the proposed system is shown on a group of ninety-two patients. In a first stage, a pool of seven rehabilitation therapists has evaluated the results of the patients on the basis of three reference rehabilitation exercises, confirming a significant gradual recovery of the patients’ skills. Moreover, the feedbacks received by the therapists and patients, who have used the system, have pointed out remarkable results in terms of motivation, usability, and customization. In a second stage, by comparing the current state-of-the-art in rehabilitation area with the proposed system, we have observed that the latter can be considered a concrete contribution in terms of versatility, immersivity, and novelty. In a final stage, by training a Gated Recurrent Unit Recurrent Neural Network (GRU-RNN) with healthy subjects (i.e., baseline), we have also provided a reference model to objectively evaluate the degree of the patients’ performance. To estimate the effectiveness of this last aspect of the proposed approach, we have used the NTU RGB + D Action Recognition dataset obtaining comparable results with the current literature in action recognition.[…]

 

Continue —-> An interactive and low-cost full body rehabilitation framework based on 3D immersive serious games – ScienceDirect

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