A task-specific interactive game-based virtual reality rehabilitation system for patients with stroke: a usability test and two clinical experiments

Joon-Ho Shin, Hokyoung Ryu, Seong Ho Jang, Joon-Ho Shin, Hokyoung Ryu, Seong Ho Jang

Abstract

Background: Virtual reality (VR) is not commonly used in clinical rehabilitation, and commercial VR gaming systems may have mixed effects in patients with stroke. Therefore, we developed RehabMaster™, a task-specific interactive game-based VR system for post-stroke rehabilitation of the upper extremities, and assessed its usability and clinical efficacy.

Methods: A participatory design and usability tests were carried out for development of RehabMaster with representative user groups. Two clinical trials were then performed. The first was an observational study in which seven patients with chronic stroke received 30 minutes of RehabMaster intervention per day for two weeks. The second was a randomised controlled trial of 16 patients with acute or subacute stroke who received 10 sessions of conventional occupational therapy only (OT-only group) or conventional occupational therapy plus 20 minutes of RehabMaster intervention (RehabMaster + OT group). The Fugl-Meyer Assessment score (FMA), modified Barthel Index (MBI), adverse effects, and drop-out rate were recorded.

Results: The requirements of a VR system for stroke rehabilitation were established and incorporated into RehabMaster. The reported advantages from the usability tests were improved attention, the immersive flow experience, and individualised intervention. The first clinical trial showed that the RehabMaster intervention improved the FMA (P = .03) and MBI (P = .04) across evaluation times. The second trial revealed that the addition of RehabMaster intervention tended to enhance the improvement in the FMA (P = .07) but did not affect the improvement in the MBI. One patient with chronic stroke left the trial, and no adverse effects were reported.

Conclusions: The RehabMaster is a feasible and safe VR system for enhancing upper extremity function in patients with stroke.

Figures

Figure 1
Figure 1
View of the experimental setup of the RehabMaster system and a screen shot of a RehabMaster game. The participant sits up in front of the monitor on which the program is projected. The participant is instructed to move his or her upper extremity (ies) and trunk in order to play the game. The RehabMaster system consists of: 1) a depth sensor, 2) a monitor with a built-in computer, 3) a monitor for the therapist, and 4) the RehabMaster system control computer for the therapist.
Figure 2
Figure 2
Flowcharts of the clinical experiments. A. Clinical experiments in patients with chronic stroke. B. Clinical experiments in patients with acute and subacute stroke.
Figure 3
Figure 3
Group mean change scores and standard error bars of Fugl-Meyer Assessment score of paretic upper limb and Modified Barthel Index in patients with chronic stroke. Abbreviations: T0, baseline; T5, after the fifth session of intervention; T10, after tenth session of intervention; T25, two weeks after intervention.

References

    1. Williams LS, Weinberger M, Harris LE, Clark DO, Biller J. Development of a stroke-specific quality of life scale. Stroke. 1999;30(7):1362–1369. doi: 10.1161/01.STR.30.7.1362.
    1. Nichols-Larsen DS, Clark P, Zeringue A, Greenspan A, Blanton S. Factors influencing stroke survivors’ quality of life during subacute recovery. Stroke. 2005;36(7):1480–1484. doi: 10.1161/01.STR.0000170706.13595.4f.
    1. Nakayama H, Jørgensen H, Raaschou HO, Olsen TS. Compensation in recovery of upper extremity function after stroke: the Copenhagen Stroke Study. Arch Phys Med Rehab. 1994;75(8):852. doi: 10.1016/0003-9993(94)90108-2.
    1. G. Broeks GL, Rumping K, AJH Prevo J. The long-term outcome of arm function after stroke: results of a follow-up study. Disabil Rehabil. 1999;21(8):357–364. doi: 10.1080/096382899297459.
    1. Langhorne P, Coupar F, Pollock A. Motor recovery after stroke: a systematic review. Lancet Neurol. 2009;8(8):741–754. doi: 10.1016/S1474-4422(09)70150-4.
    1. Jutai JW, Teasell RW. The necessity and limitations of evidence-based practice in stroke rehabilitation. Top Stroke Rehabil. 2003;10(1):71–78.
    1. Rose F, Attree E, Johnson D. Virtual reality: an assistive technology in neurological rehabilitation. Curr Opin Neurol. 1996;9(6):461. doi: 10.1097/00019052-199612000-00012.
    1. Merians AS, Jack D, Boian R, Tremaine M, Burdea GC, Adamovich SV, Recce M, Poizner H. Virtual reality–augmented rehabilitation for patients following stroke. Phys Ther. 2002;82(9):898–915.
    1. Lamberto Piron M, Andrea Turolla P, Michela Agostini P, Carla Zucconi P, Feliciana Cortese M, Mauro Zampolini M, Mara Zannini P, Mauro Dam M. Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach. Rehabil Med. 2009;41:1016–1020. doi: 10.2340/16501977-0459.
    1. Mouawad MR, Doust CG, Max MD, McNulty PA. Wii-based movement therapy to promote improved upper extremity function post-stroke: a pilot study. J Rehabil Med. 2011;43(6):527–533. doi: 10.2340/16501977-0816.
    1. Saposnik G, Teasell R, Mamdani M, Hall J, McIlroy W, Cheung D, Thorpe KE, Cohen LG, Bayley M. Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation a pilot randomized clinical trial and proof of principle. Stroke. 2010;41(7):1477–1484. doi: 10.1161/STROKEAHA.110.584979.
    1. Yavuzer G, Senel A, Atay M, Stam H. Playstation eyetoy games” improve upper extremity-related motor functioning in subacute stroke: a randomized controlled clinical trial. Eur J Phys Rehabil Med. 2008;44(3):237–244.
    1. Chang YJ, Chen SF, Huang JD. A Kinect-based system for physical rehabilitation: a pilot study for young adults with motor disabilities. Res Dev Disabil. 2011;32(6):2566–2570. doi: 10.1016/j.ridd.2011.07.002.
    1. Ustinova KI, Leonard WA, Cassavaugh ND, Ingersoll CD. Development of a 3D immersive videogame to improve arm-postural coordination in patients with TBI. J Neuroeng Rehabil. 2011;8:61. doi: 10.1186/1743-0003-8-61.
    1. Lange B, Flynn S, Rizzo A. Initial usability assessment of off-the-shelf video game consoles for clinical game-based motor rehabilitation. Phys Ther Rev. 2009;14(5):355–363. doi: 10.1179/108331909X12488667117258.
    1. Prensky M. The digital game-based learning revolution. New York: McGraw-Hill; 2004.
    1. Graesser AC, Wiemer-Hastings K, Wiemer-Hastings P, Kreuz R. AutoTutor: A simulation of a human tutor. Cogn Syst Res. 1999;1(1):35–51. doi: 10.1016/S1389-0417(99)00005-4.
    1. Salen K, Zimmerman E. Rules of play: Game design fundamentals. Cambridge: The MIT Press; 2004.
    1. Gladstone DJ, Danells CJ, Black SE. The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties. Neurorehabil Neural Repair. 2002;16(3):232–240. doi: 10.1177/154596802401105171.
    1. Yozbatiran N, Der-Yeghiaian L, Cramer SC. A standardized approach to performing the action research arm test. Neurorehab Neural Re. 2008;22(1):78–90.
    1. Demeurisse G, Demol O, Robaye E. Motor evaluation in vascular hemiplegia. Eur Neurol. 1980;19(6):382–389. doi: 10.1159/000115178.
    1. Csikszentmihalyi M. Flow: The Psychology of Optimal Experience. London: Harper Perennial; 1990.
    1. Van Allen MW. Aids to the examination of the peripheral nervous system. Arch Neurol. 1977;34(1):61.
    1. Brunnstrom S. Motor testing procedures in hemiplegia: based on sequential recovery stages. Phys Ther. 1966;46(4):357.
    1. Fugl-Meyer A, Jääskö L, Leyman I, Olsson S, Steglind S. The post-stroke hemiplegic patient. 1. a method for evaluation of physical performance. Scand J Rehabil Med. 1975;7(1):13.
    1. Shah S, Vanclay F, Cooper B. Improving the sensitivity of the Barthel Index for stroke rehabilitation. J Clin Epidemiol. 1989;42(8):703–709. doi: 10.1016/0895-4356(89)90065-6.
    1. De Angeli A, Sutcliffe A, Hartmann J. Proceedings of the 6th Conference on Designing Interactive Systems: 2006. New York: ACM; 2006. Interaction, usability and aesthetics: what influences users’ preferences ; pp. 271–280.
    1. Park J, Parsons D, Ryu H. To flow and not to freeze: Applying flow experience to mobile learning. Learn Tech, IEEE Trans. 2010;3(1):56–67.
    1. da Silva CM, Bermudez IBS, Duarte E, Verschure PF. Virtual reality based rehabilitation speeds up functional recovery of the upper extremities after stroke: a randomized controlled pilot study in the acute phase of stroke using the rehabilitation gaming system. Restor Neurol Neurosci. 2011;29(5):287–298.
    1. Cameirao MS, Badia SB, Oller ED, Verschure PF. Neurorehabilitation using the virtual reality based Rehabilitation Gaming System: methodology, design, psychometrics, usability and validation. J Neuroeng Rehabil. 2010;7:48. doi: 10.1186/1743-0003-7-48.
    1. Page SJ. Intensity versus task-specificity after stroke: how important is intensity . Am J P M R. 2003;82(9):730. doi: 10.1097/01.PHM.0000078226.36000.A5.
    1. Wolf SL, Thompson PA, Winstein CJ, Miller JP, Blanton SR, Nichols-Larsen DS, Morris DM, Uswatte G, Taub E, Light KE. The EXCITE stroke trial. Stroke. 2010;41(10):2309–2315. doi: 10.1161/STROKEAHA.110.588723.
    1. Wolf SL, Winstein CJ, Miller JP, Taub E, Uswatte G, Morris D, Giuliani C, Light KE, Nichols-Larsen D, Investigators E. Effect of constraint-induced movement therapy on upper extremity function 3 to 9 months after stroke: the EXCITE randomized clinical trial. JAMA. 2006;296(17):2095–2104. doi: 10.1001/jama.296.17.2095.
    1. Johansson BB. Current trends in stroke rehabilitation. A review with focus on brain plasticity. Acta Neurol Scand. 2011;123(3):147–159. doi: 10.1111/j.1600-0404.2010.01417.x.
    1. Rahman S, Shaheen A. Virtual reality use in motor rehabilitation of neurological disorders: A systematic review. Middle-East J Sci Res. 2011;7(1):63–70.

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