Can telerehabilitation games lead to functional improvement of upper extremities in individuals with Parkinson's disease?

Abstract

Parkinson's disease (PD) is treated by medication, less with deep brain stimulation and physiotherapy. Different opinions on the clinical meaningfulness of the physiotherapy or recommended intensive physiotherapy were found. Our objectives were to design intensive target-based physiotherapy for upper extremities suitable for telerehabilitation services and examine the clinical meaningfulness of the exergaming at an unchanged medication plan. A telerehabilitation exergaming system using the Kinect sensor was developed; 28 patients with PD participated in the study. The system followed the participants' movements and adapted the difficulty level of the game in real time. The outcomes of the study showed that seven out of 26 participants could set up the equipment at home alone. Clinical outcomes of Box and Blocks Test (mean: 47 vs. 52, P=0.002, Cohen's d=0.40), UPDRS III (mean: 27 vs. 29, P=0.001, d=0.22), and daily activity Jebsen's test; writing a letter (mean: 24.0 vs. 20.6, P=0.003, d=0.23); and moving light objects (mean: 4.4 vs. 3.9, P=0.006, d=0.46) were statistically significant (P<0.05) and considered clinically meaningful. The Nine-Hole Peg Test showed a statistically nonsignificant improvement (mean: 28.0 vs. 26.5, P=0.089, d=0.22). The participants claimed problems with mobility but less with activities of daily living and emotional well-being (PDQ-39). The findings lead to preliminary conclusions that exergaming is feasible, but may require technical assistance, whereas clinically meaningful results could be achieved according to validated instruments and an unchanged medication plan in individuals with PD.

Figures

Fig. 1

Flow diagram.

Fig. 2

An individual with Parkinson’s disease performing a target-based exercise at home. The game requires full cooperation and the difficulty level can be adapted in real time during the exergaming.

Fig. 3

System for telerehabilitation of the upper extremities enables remote access to the data.

Fig. 4

The outcomes of the ‘Fruit picking’ game compared with the clinical tests. The final game score (apples×levels) increased from 69.88 to 237 (P=0.000, d=1.79) until the end of exergaming therapy as shown in the upper left plot. However, regression coefficients were rather low for a direct match between the game score and particular clinical tests; R2=0.0649 for Box and Block Test (BBT), R2=0.0509 for Unified Parkinson’s Disease Rating Scale (UPDRS III) and R2=0.007 for writing a letter (WAL) in the lower right plot.

Fig. 5

The results obtained from the clinical tests Nine-Hole Peg Hole Test (9HPT), Box and Block Test (BBT), Unified Parkinson’s Disease Rating Scale (UPDRS III), and Jebsen’s test [writing a letter (WAL), Card turning (CTURN), Stacking checkers (STCHK), stimulated feeding (SFEED), moving light objects (MLO), moving heavy objects (MHO), small objects picking (SOP)]. The changes marked with * are statistically significant (P<0.05). The boxes present the first quantile (25%) and the third quantile (75%) of the data and whiskers are 1.5 times the interquartile range (corresponds to 99.3% coverage). Data points beyond the whiskers are outliers.

Fig. 6

Parkinson’s Disease Questionnaire (PDQ-39) results assessed in the patients with Parkinson’s disease continuing with exergaming at home. The total score of each dimension ranges from 0 (never have difficulty) to 100 (always have difficulty). Lower scores indicate better quality of life.