Virtual Reality-Based Rehabilitation as a Feasible and Engaging Tool for the Management of Chronic Poststroke Upper-Extremity Function Recovery: Randomized Controlled Trial

Alejandro Hernandez, Liudmila Bubyr, Philippe S Archambault, Johanne Higgins, Mindy F Levin, Dahlia Kairy, Alejandro Hernandez, Liudmila Bubyr, Philippe S Archambault, Johanne Higgins, Mindy F Levin, Dahlia Kairy

Abstract

Background: A growing number of stroke survivors are left with little to no rehabilitation services upon discharge from stroke rehabilitation, although arm deficits may persist or develop from disuse once rehabilitation services have ceased. Virtual reality (VR)-based rehabilitation, combined with new technologies such as telerehabilitation, including serious games using VR environments that encourage users to practice functional movements from home with minimal supervision, may have an important role to play in optimizing and maintaining upper extremity (UE) function.

Objective: The primary objective of this study is to determine the extent to which a 1-month intervention using a VR-based serious game is effective in improving UE function compared with an evidence-based home exercise program. A secondary objective is to assess the feasibility of implementing the intervention for chronic stroke rehabilitation in participants' homes.

Methods: A total of 51 chronic stroke participants were randomized to treatment (n=26, 51%; Jintronix system) or standard care (n=25, 49%; standardized Graded Repetitive Arm Supplementary Program kit home program) groups. The participants were evaluated at baseline (before), immediately after the intervention (after), and at follow-up (4 weeks). The primary outcome measure was the Fugl-Meyer Assessment for UE (FMA-UE). Secondary outcome measures included the Stroke Impact Scale and an abridged version of the Motor Activity Log-14. Self-reported number of sessions was logged for the standard care group.

Results: No statistically significant differences between groups were found across measures. Overall time effects were found for the FMA-UE (P=.045), specifically between preintervention and postintervention time points for both groups (P=.03). A total of 9 participants in the treatment group reached or surpassed the minimal clinically important difference in scores for the FMA-UE, with 7 (78%) of them having baseline low or moderate arm function, compared with 3 (33%) participants in the standard care group. Furthermore, 56% (9/16) of the participants in the treatment group who actively engaged with the system reached the minimal clinically important difference for the FMA-UE, compared with none for the 0% (0/10) less-active participants.

Conclusions: These findings suggest that UE training for chronic stroke survivors using virtual rehabilitation in their home may be as effective as a gold standard home exercise program and that those who used the system the most achieved the greatest improvement in UE function, indicating its relevance to being included as part of ongoing rehabilitation services.

Trial registration: ClinicalTrials.gov NCT02491203; https://ichgcp.net/clinical-trials-registry/NCT02491203.

International registered report identifier (irrid): RR2-10.1016/j.cct.2015.12.006.

Keywords: rehabilitation; serious game; stroke; telerehabilitation; upper extremity; virtual care; virtual reality; virtual reality–based rehabilitation.

Conflict of interest statement

Conflicts of Interest: None declared.

©Alejandro Hernandez, Liudmila Bubyr, Philippe S Archambault, Johanne Higgins, Mindy F Levin, Dahlia Kairy. Originally published in JMIR Serious Games (https://games.jmir.org), 27.09.2022.

Figures

Figure 1
Figure 1
The Jintronix system. Clockwise from top left: Fish Frenzy, Catch-Carry-Drop, Kitchen, Pop Clap game activities.
Figure 2
Figure 2
Flow diagram of the study’s enrollment process.
Figure 3
Figure 3
Left: median Fugl-Meyer Assessment for upper-extremity (FMA-UE) score over time by group; right: by group and baseline arm function.
Figure 4
Figure 4
Change in median Fugl-Meyer Assessment for upper-extremity (FMA-UE) score after intervention for treatment group participants; by baseline arm function and level of gameplay duration. MCID: minimal clinically important difference.

References

    1. Teasell R, Salbach NM, Foley N, Mountain A, Cameron JI, Jong AD, Acerra NE, Bastasi D, Carter SL, Fung J, Halabi ML, Iruthayarajah J, Harris J, Kim E, Noland A, Pooyania S, Rochette A, Stack BD, Symcox E, Timpson D, Varghese S, Verrilli S, Gubitz G, Casaubon LK, Dowlatshahi D, Lindsay MP. Canadian stroke best practice recommendations: rehabilitation, recovery, and community participation following stroke. Part one: rehabilitation and recovery following stroke; 6th edition update 2019. Int J Stroke. 2020 Oct;15(7):763–88. doi: 10.1177/1747493019897843.
    1. Kwakkel G, Kollen BJ, van der Grond J, Prevo AJ. Probability of regaining dexterity in the flaccid upper limb: impact of severity of paresis and time since onset in acute stroke. Stroke. 2003 Sep;34(9):2181–6. doi: 10.1161/
    1. Holden MK, Dyar TA, Dayan-Cimadoro L. Telerehabilitation using a virtual environment improves upper extremity function in patients with stroke. IEEE Trans Neural Syst Rehabil Eng. 2007 Mar;15(1):36–42. doi: 10.1109/TNSRE.2007.891388.
    1. Sibley LM, Glazier RH. Reasons for self-reported unmet healthcare needs in Canada: a population-based provincial comparison. Healthc Policy. 2009 Aug;5(1):87–101.
    1. Lang CE, Lohse KR, Birkenmeier RL. Dose and timing in neurorehabilitation: prescribing motor therapy after stroke. Curr Opin Neurol. 2015 Dec;28(6):549–55. doi: 10.1097/WCO.0000000000000256.
    1. McCabe J, Monkiewicz M, Holcomb J, Pundik S, Daly JJ. Comparison of robotics, functional electrical stimulation, and motor learning methods for treatment of persistent upper extremity dysfunction after stroke: a randomized controlled trial. Arch Phys Med Rehabil. 2015 Jun;96(6):981–90. doi: 10.1016/j.apmr.2014.10.022. S0003-9993(14)01228-3
    1. Ward NS, Brander F, Kelly K. Intensive upper limb neurorehabilitation in chronic stroke: outcomes from the Queen Square programme. J Neurol Neurosurg Psychiatry. 2019 May;90(5):498–506. doi: 10.1136/jnnp-2018-319954.jnnp-2018-319954
    1. Brennan DM, Mawson S, Brownsell S. Telerehabilitation: enabling the remote delivery of healthcare, rehabilitation, and self management. Stud Health Technol Inform. 2009;145:231–48.
    1. Dodakian L, McKenzie AL, Le V, See J, Pearson-Fuhrhop K, Burke Quinlan E, Zhou RJ, Augsberger R, Tran XA, Friedman N, Reinkensmeyer DJ, Cramer SC. A home-based telerehabilitation program for patients with stroke. Neurorehabil Neural Repair. 2017;31(10-11):923–33. doi: 10.1177/1545968317733818.
    1. Sarfo FS, Ulasavets U, Opare-Sem OK, Ovbiagele B. Tele-rehabilitation after stroke: an updated systematic review of the literature. J Stroke Cerebrovasc Dis. 2018 Sep;27(9):2306–18. doi: 10.1016/j.jstrokecerebrovasdis.2018.05.013. S1052-3057(18)30231-3
    1. Bonnechère B, Jansen B, Omelina L, Van Sint Jan S. The use of commercial video games in rehabilitation: a systematic review. Int J Rehabil Res. 2016 Dec;39(4):277–90. doi: 10.1097/MRR.0000000000000190.
    1. Pietrzak E, Cotea C, Pullman S. Using commercial video games for upper limb stroke rehabilitation: is this the way of the future? Top Stroke Rehabil. 2014;21(2):152–62. doi: 10.1310/tsr2102-152.Y7TV8H4402716T01
    1. Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2017 Nov 20;11(11):CD008349. doi: 10.1002/14651858.CD008349.pub4.
    1. Norouzi-Gheidari N, Hernandez A, Archambault PS, Higgins J, Poissant L, Kairy D. Feasibility, safety and efficacy of a virtual reality exergame system to supplement upper extremity rehabilitation post-stroke: a pilot randomized clinical trial and proof of principle. Int J Environ Res Public Health. 2019 Dec 23;17(1):113. doi: 10.3390/ijerph17010113. ijerph17010113
    1. Huijgen BC, Vollenbroek-Hutten MM, Zampolini M, Opisso E, Bernabeu M, Van Nieuwenhoven J, Ilsbroukx S, Magni R, Giacomozzi C, Marcellari V, Marchese SS, Hermens HJ. Feasibility of a home-based telerehabilitation system compared to usual care: arm/hand function in patients with stroke, traumatic brain injury and multiple sclerosis. J Telemed Telecare. 2008;14(5):249–56. doi: 10.1258/jtt.2008.080104.14/5/249
    1. Hsieh YW, Chang KC, Hung JW, Wu CY, Fu MH, Chen CC. Effects of home-based versus clinic-based rehabilitation combining mirror therapy and task-specific training for patients with stroke: a randomized crossover trial. Arch Phys Med Rehabil. 2018 Dec;99(12):2399–407. doi: 10.1016/j.apmr.2018.03.017.S0003-9993(18)30236-3
    1. Langan J, Delave K, Phillips L, Pangilinan P, Brown SH. Home-based telerehabilitation shows improved upper limb function in adults with chronic stroke: a pilot study. J Rehabil Med. 2013 Feb;45(2):217–20. doi: 10.2340/16501977-1115.
    1. Schulz KF, Altman DG, Moher D, CONSORT Group CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ. 2010 Mar 23;340:c332. doi: 10.1136/bmj.c332.
    1. Gowland C, Stratford P, Ward M, Moreland J, Torresin W, Van Hullenaar S, Sanford J, Barreca S, Vanspall B, Plews N. Measuring physical impairment and disability with the Chedoke-McMaster Stroke Assessment. Stroke. 1993 Jan;24(1):58–63. doi: 10.1161/01.str.24.1.58.
    1. Harris JE, Eng JJ, Miller WC, Dawson AS. A self-administered Graded Repetitive Arm Supplementary Program (GRASP) improves arm function during inpatient stroke rehabilitation: a multi-site randomized controlled trial. Stroke. 2009 Jun;40(6):2123–8. doi: 10.1161/STROKEAHA.108.544585.STROKEAHA.108.544585
    1. Rand D, Weingarden H, Weiss R, Yacoby A, Reif S, Malka R, Shiller DA, Zeilig G. Self-training to improve UE function at the chronic stage post-stroke: a pilot randomized controlled trial. Disabil Rehabil. 2017 Jul;39(15):1541–8. doi: 10.1080/09638288.2016.1239766.
    1. Sanford J, Moreland J, Swanson LR, Stratford PW, Gowland C. Reliability of the Fugl-Meyer assessment for testing motor performance in patients following stroke. Phys Ther. 1993 Jul;73(7):447–54. doi: 10.1093/ptj/73.7.447.
    1. Veras M, Kairy D, Rogante M, Giacomozzi C, Saraiva S. Scoping review of outcome measures used in telerehabilitation and virtual reality for post-stroke rehabilitation. J Telemed Telecare. 2017 Jul;23(6):567–87. doi: 10.1177/1357633X16656235.1357633X16656235
    1. Uswatte G, Taub E, Morris D, Vignolo M, McCulloch K. Reliability and validity of the upper-extremity Motor Activity Log-14 for measuring real-world arm use. Stroke. 2005 Nov;36(11):2493–6. doi: 10.1161/01.STR.0000185928.90848.2e.01.STR.0000185928.90848.2e
    1. Vellone E, Savini S, Fida R, Dickson V, Melkus G, Carod-Artal F, Rocco G, Alvaro R. Psychometric evaluation of the Stroke Impact Scale 3.0. J Cardiovasc Nurs. 2015;30(3):229–41. doi: 10.1097/JCN.0000000000000145.
    1. McHugh ML. Descriptive statistics, part II: most commonly used descriptive statistics. J Spec Pediatr Nurs. 2003;8(3):111–6. doi: 10.1111/j.1088-145x.2003.00111.x.
    1. Woodbury ML, Velozo CA, Richards LG, Duncan PW. Rasch analysis staging methodology to classify upper extremity movement impairment after stroke. Arch Phys Med Rehabil. 2013 Aug;94(8):1527–33. doi: 10.1016/j.apmr.2013.03.007.S0003-9993(13)00239-6
    1. Hoonhorst MH, Nijland RH, van den Berg JS, Emmelot CH, Kollen BJ, Kwakkel G. How do Fugl-Meyer arm motor scores relate to dexterity according to the action research arm test at 6 months poststroke? Arch Phys Med Rehabil. 2015 Oct;96(10):1845–9. doi: 10.1016/j.apmr.2015.06.009.S0003-9993(15)00489-X
    1. Llorens R, Noé E, Alcañiz M, Deutsch JE. Time since injury limits but does not prevent improvement and maintenance of gains in balance in chronic stroke. Brain Inj. 2018;32(3):303–9. doi: 10.1080/02699052.2017.1418905.
    1. Hung JW, Chou CX, Chang YJ, Wu CY, Chang KC, Wu WC, Howell S. Comparison of Kinect2Scratch game-based training and therapist-based training for the improvement of upper extremity functions of patients with chronic stroke: a randomized controlled single-blinded trial. Eur J Phys Rehabil Med. 2019 Oct;55(5):542–50. doi: 10.23736/S1973-9087.19.05598-9. S1973-9087.19.05598-9
    1. Langhorne P, Wagenaar R, Partridge C. Physiotherapy after stroke: more is better? Physiother Res Int. 1996;1(2):75–88. doi: 10.1002/pri.6120010204.
    1. Trombetta M, Bazzanello Henrique PP, Brum MR, Colussi EL, De Marchi AC, Rieder R. Motion Rehab AVE 3D: a VR-based exergame for post-stroke rehabilitation. Comput Methods Programs Biomed. 2017 Nov;151:15–20. doi: 10.1016/j.cmpb.2017.08.008.S0169-2607(17)30113-X
    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 Sep;16(3):232–40. doi: 10.1177/154596802401105171.
    1. Held JP, Klaassen B, Eenhoorn A, van Beijnum BJ, Buurke JH, Veltink PH, Luft AR. Inertial sensor measurements of upper-limb kinematics in stroke patients in clinic and home environment. Front Bioeng Biotechnol. 2018 Apr 12;6:27. doi: 10.3389/fbioe.2018.00027. doi: 10.3389/fbioe.2018.00027.
    1. Duret C, Courtial O, Grosmaire AG. Kinematic measures for upper limb motor assessment during robot-mediated training in patients with severe sub-acute stroke. Restor Neurol Neurosci. 2016;34(2):237–45. doi: 10.3233/RNN-150565.RNN150565
    1. Villepinte C, Verma A, Dimeglio C, De Boissezon X, Gasq D. Responsiveness of kinematic and clinical measures of upper-limb motor function after stroke: a systematic review and meta-analysis. Ann Phys Rehabil Med. 2021 Mar;64(2):101366. doi: 10.1016/j.rehab.2020.02.005. S1877-0657(20)30059-2
    1. Parker J, Powell L, Mawson S. Effectiveness of upper limb wearable technology for improving activity and participation in adult stroke survivors: systematic review. J Med Internet Res. 2020 Jan 08;22(1):e15981. doi: 10.2196/15981. v22i1e15981
    1. Kim WS, Cho S, Baek D, Bang H, Paik NJ. Upper extremity functional evaluation by Fugl-Meyer assessment scoring using depth-sensing camera in hemiplegic stroke patients. PLoS One. 2016 Jul 1;11(7):e0158640. doi: 10.1371/journal.pone.0158640. PONE-D-16-09834
    1. Piron L, Turolla A, Agostini M, Zucconi C, Cortese F, Zampolini M, Zannini M, Dam M, Ventura L, Battauz M, Tonin P. Exercises for paretic upper limb after stroke: a combined virtual-reality and telemedicine approach. J Rehabil Med. 2009 Nov;41(12):1016–102. doi: 10.2340/16501977-0459.
    1. Henrique PP, Colussi EL, De Marchi AC. Effects of exergame on patients' balance and upper limb motor function after stroke: a randomized controlled trial. J Stroke Cerebrovasc Dis. 2019 Aug;28(8):2351–7. doi: 10.1016/j.jstrokecerebrovasdis.2019.05.031.S1052-3057(19)30268-X
    1. Lohse KR, Lang CE, Boyd LA. Is more better? Using metadata to explore dose-response relationships in stroke rehabilitation. Stroke. 2014 Jul;45(7):2053–8. doi: 10.1161/STROKEAHA.114.004695. STROKEAHA.114.004695
    1. Page SJ, Gater DR, Bach-Y-Rita P. Reconsidering the motor recovery plateau in stroke rehabilitation. Arch Phys Med Rehabil. 2004 Aug;85(8):1377–81. doi: 10.1016/j.apmr.2003.12.031.S0003-9993(04)00261-8
    1. Coupar F, Pollock A, Legg LA, Sackley C, van Vliet P. Home-based therapy programmes for upper limb functional recovery following stroke. Cochrane Database Syst Rev. 2012 May 16;2012(5):CD006755. doi: 10.1002/14651858.CD006755.pub2.
    1. Tsekleves E, Paraskevopoulos IT, Warland A, Kilbride C. Development and preliminary evaluation of a novel low cost VR-based upper limb stroke rehabilitation platform using Wii technology. Disabil Rehabil Assist Technol. 2016;11(5):413–22. doi: 10.3109/17483107.2014.981874.
    1. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD, American Heart Association Stroke Council‚ Council on Cardiovascular and Stroke Nursing‚ Council on Clinical Cardiology‚ and Council on Quality of Care and Outcomes Research Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016 Jun;47(6):e98–169. doi: 10.1161/STR.0000000000000098.STR.0000000000000098

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