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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.[…]
arm rehabilitation, Dynamic difficulty adaptation, Exercise intensity, Interpersonal rehabilitation games, Motivation, Multiplayer games, Social Interaction, UE, UL, Upper Extremity, upper limb, virtual reality
[ARTICLE] Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity – Full Text
People with chronic arm impairment should exercise intensely to regain their abilities, but frequently lack motivation, leading to poor rehabilitation outcome. One promising way to increase motivation is through interpersonal rehabilitation games, which allow patients to compete or cooperate together with other people. However, such games have mainly been evaluated with unimpaired subjects, and little is known about how they affect motivation and exercise intensity in people with chronic arm impairment.
We designed four different arm rehabilitation games that are played by a person with arm impairment and their unimpaired friend, relative or occupational therapist. One is a competitive game (both people compete against each other), two are cooperative games (both people work together against the computer) and one is a single-player game (played only by the impaired person against the computer). The games were played by 29 participants with chronic arm impairment, of which 19 were accompanied by their friend or relative and 10 were accompanied by their occupational therapist. Each participant played all four games within a single session. Participants’ subjective experience was quantified using the Intrinsic Motivation Inventory questionnaire after each game, as well as a final questionnaire about game preferences. Their exercise intensity was quantified using wearable inertial sensors that measured hand velocity in each game.
Of the 29 impaired participants, 12 chose the competitive game as their favorite, 12 chose a cooperative game, and 5 preferred to exercise alone. Participants who chose the competitive game as their favorite showed increased motivation and exercise intensity in that game compared to other games. Participants who chose a cooperative game as their favorite also showed increased motivation in cooperative games, but not increased exercise intensity.
Since both motivation and intensity are positively correlated with rehabilitation outcome, competitive games have high potential to lead to functional improvement and increased quality of life for patients compared to conventional rehabilitation exercises. Cooperative games do not increase exercise intensity, but could still increase motivation of patients who do not enjoy competition. However, such games need to be tested in longer, multisession studies to determine whether the observed increases in motivation and exercise intensity persist over a longer period of time and whether they positively affect rehabilitation outcome.
The study is not a clinical trial. While human subjects are involved, they participate in a single-session evaluation of a rehabilitation game rather than a full rehabilitation intervention, and no health outcomes are examined.
Rehabilitation ,Virtual reality ,Multiplayer games, Interpersonal rehabilitation games ,Social interaction ,Motivation ,Exercise intensity
Home rehabilitation technology
Diseases such as stroke have a massively debilitating effect on people’s lives. It is estimated that one in six people will experience a stroke in their lifetime , and 88% of survivors report some impairment of their limb function . In the United States, approximately 795,000 individuals suffer a new or recurrent stroke every year, leading to an estimated combined direct and indirect cost of $68.9 billion . Intensive training delivered by a therapist soon after the injury can effectively restore motor functions needed for independent life. However, even top hospitals only devote a limited amount of time to rehabilitation of motor functions . The situation is even worse in most other hospitals and health centers, where patients are idle for most of the day due to a shortage of qualified medical staff . After leaving the hospital, patients thus need to exercise at home without therapist supervision in order to fully regain their abilities.
Several technologies, ranging from consumer devices such as the Microsoft Kinect  to complex exoskeletons , have been deployed for motor rehabilitation at home. These technologies usually combine limb tracking with virtual environments presented on a personal computer, which allow patients to perform a variety of simulated activities of daily living . Furthermore, they incorporate game-like elements such as automated difficulty adaptation, score displays and cognitive challenges [8, 9, 10, 11]. However, despite promising technical achievements, the effectiveness of home rehabilitation technology remains limited. A recent study showed that, even if a therapist prescribes a technology-supported exercise, only about 30% of unsupervised patients will comply with the rehabilitation regimen .
This lack of compliance is due to lack of motivation for rehabilitation, which is known to be a key determinant of rehabilitation outcome: patients who are unmotivated will not exercise frequently or intensely enough [13, 14]. Studies outside rehabilitation have already shown that motivational interventions improve compliance with the therapy regimen , and recent home rehabilitation studies have emphasized the importance of motivational elements that would increase the duration and intensity of exercise [16, 17]…
Continue —> Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity | Journal of NeuroEngineering and Rehabilitation | Full Text
[ARTICLE] Multi-User Virtual Reality Therapy for Post-Stroke Hand Rehabilitation at Home. – Full Text PDF
Our paper describes the development of a novel multi-user virtual reality (VR) system for post-stroke rehabilitation that can be used independently in the home to improve upper extremity motor function. This is the pre-clinical phase of an ongoing collaborative, interdisciplinary research project at the Rehabilitation Institute of Chicago involving a team of engineers, researchers, occupational therapists and artists. This system was designed for creative collaboration within a virtual environment to increase patients’ motivation, further engagement and to alleviate the impact of social isolation following stroke. This is a low-cost system adapted to everyday environments and designed to run on a personal computer that combines three VR environments with audio integration, wireless Kinect tracking and hand motion tracking sensors. Three different game exercises for this system were developed to encourage repetitive task practice, collaboration and competitive interaction. The system is currently being tested with 15 subjects in three settings: a multi-user VR, a single-user VR and at a tabletop with standard exercises to examine the level of engagement and to compare resulting functional performance across methods. We hypothesize that stroke survivors will become more engaged in therapy when training with a multi-user VR system and this will translate into greater gains.
Stroke is the leading cause of major, long-term disability in adults in the United States . Every 40 seconds someone in
the U.S. has a stroke  and more than 700,000 people suffer a new or recurrent stroke each year. The majority of stroke survivors endure chronic impairment , which dramatically impacts their lives physically, psychologically and socially. Stroke incidence is even greater in low to middle income countries. Around 50% of all stroke survivors will have residual hemiparesis involving the upper extremity [4, 5], which can have a profound, adverse impact on self-care, employment, and overall quality of life. A number of studies [6, 7, 8, 9] have shown that upper extremity motor control can still be improved, even in stroke survivors with chronic hemiparesis subsequent to stroke. Many patients continue to be highly motivated to achieve further gains after standard rehabilitation has been completed, seeking out new methods, technologies and practices that can improve upper extremity motor control.
Repetitive movement practice proved to be crucial for maximizing therapeutic benefits . The necessary repetition of rehabilitation exercises can be tedious, however [10, 11, 12] and many patients, including stroke survivors, discontinue treatment long before optimal results have been achieved. Lack of motivation, disengagement, and boredom contribute to impeded progress in rehabilitation . Additionally, opportunities for task practice in the clinic are becoming increasingly limited due to shortened hospital stays  and a reduced number of allotted outpatient therapy sessions (Figure 1). Furthermore, lack of transportation can prevent outpatient stroke survivors from taking full advantage of the available therapy sessions.
Tele-rehabilitation seems a possible solution, but current telerehabilitation systems [7, 16] largely consist of teleconferencing between the therapist and the client. Therapist-client interaction is limited and quantitative measurement of performance is lacking. Instead, we propose a multi-user virtual reality environment (VRE) in which the therapist and client can interact with each other and with objects in the VRE.
An inexpensive motion capture system allows control of avatars, as well as collection of movement kinematics. Our system is innovative, because it brings the therapist and client together in the virtual space to work together in real-time. Alternatively, or additionally, the client can participate with a training partner, potentially another patient, providing additional motivation and encouragement. One study showed that impaired subjects prefer competitive/cooperative multi-user rehabilitation games compare to single-user rehabilitation games . This system can mitigate issues related to transportation and limited clinical access by providing home-based training environment developed specifically for upper extremity rehabilitation.
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