Interaction Modalities Used on Serious Games for Upper Limb Rehabilitation: A Systematic Review

Virtual Reality-Based Exercise Rehabilitation in Cancer-Related Dysfunctions: Scoping Review

BACKGROUND

Virtual reality-based exercise rehabilitation (VRER) is a promising intervention for patients with cancer-related dysfunctions (CRDs). However, studies focusing on VRER for CRDs are lacking, and the results are inconsistent.

OBJECTIVE

We aimed to review the application of VRER in patients with CRDs.

METHODS

This scoping review was conducted following the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist framework. Publications were included from the time of database establishment to October 14, 2023. The databases were PubMed, Embase, Scopus, Cochrane, Web of Science, ProQuest, arXiv, IEEE Xplore, MedRxiv, CNKI, Wanfang Data, VIP, and SinoMed. The population included patients with cancer. A virtual reality (VR) system or device was required to be provided in exercise rehabilitation as an intervention. Eligible studies focused on VRER used for CRDs. Study selection and data extraction were performed by 2 reviewers independently. Extracted data included authors, year, country, study type, groups, sample size, participant age, cancer type, existing or potential CRDs, VR models and devices, intervention programs and durations, effectiveness, compliance, satisfaction, and safety.

RESULTS

We identified 25 articles, and among these, 12 (48%) were randomized clinical trials, 11 (44%) were other experimental studies, and 2 (8%) were observational studies. The total sample size was 1174 (range 6-136). Among the 25 studies, 22 (88%), 2 (8%), and 1 (4%) included nonimmersive VR, immersive VR, and augmented reality, respectively, which are models of VRER. Commercial game programs (17/25, 68%) were the most popular interventions of VRER, and their duration ranged from 3 to 12 weeks. Using these models and devices, VRER was mostly applied in patients with breast cancer (14/25, 56%), leukemia (8/25, 32%), and lung cancer (3/25, 12%). Furthermore, 6 CRDs were intervened by VRER, and among these, postmastectomy syndromes were the most common (10/25, 40%). Overall, 74% (17/23) of studies reported positive results, including significant improvements in limb function, joint range of motion, edema rates, cognition, respiratory disturbance index, apnea, activities of daily living, and quality of life. The compliance rate ranged from 56% to 100%. Overall, 32% (8/25) of studies reported on patient satisfaction, and of these, 88% (7/8) reported satisfaction with VRER. Moreover, 13% (1/8) reported mild sickness as an adverse event.

CONCLUSIONS

We found that around half of the studies reported using VRER in patients with breast cancer and postmastectomy dysfunctions through nonimmersive models and commercial game programs having durations of 3-12 weeks. In addition, most studies showed that VRER was effective owing to virtualization and interaction. Therefore, VRER may be an alternate intervention for patients with CRDs. However, as the conclusions were drawn from data with acknowledged inconsistencies and limited satisfaction reports, studies with larger sample sizes and more outcome indictors are required.

A Software Engineering Framework for Reusable Design of Personalized Serious Games for Health: Development Study

BACKGROUND

The use of serious games in health care is on the rise, as these games motivate treatment adherence, reduce treatment costs, and educate patients and families. However, current serious games fail to offer personalized interventions, ignoring the need to abandon the one-size-fits-all approach. Moreover, these games, with a primary objective other than pure entertainment, are costly and complex to develop and require the constant involvement of a multidisciplinary team. No standardized approach exists on how serious games can be personalized, as existing literature focuses on specific use cases and scenarios. The serious game development domain fails to consider any transfer of domain knowledge, which means this labor-intensive process must be repeated for each serious game.

OBJECTIVE

We proposed a software engineering framework that aims to streamline the multidisciplinary design process of personalized serious games in health care and facilitates the reuse of domain knowledge and personalization algorithms. By focusing on the transfer of knowledge to new serious games by reusing components and personalization algorithms, the comparison and evaluation of different personalization strategies can be simplified and expedited. In doing so, the first steps are taken in advancing the state of the art of knowledge regarding personalized serious games in health care.

METHODS

The proposed framework aimed to answer 3 questions that need to be asked when designing personalized serious games: Why is the game personalized? What parameters can be used for personalization? and How is the personalization achieved? The 3 involved stakeholders, namely, the domain expert, the (game) developer, and the software engineer, were each assigned a question and then assigned responsibilities regarding the design of the personalized serious game. The (game) developer was responsible for all the game-related components; the domain expert was in charge of the modeling of the domain knowledge using simple or complex concepts (eg, ontologies); and the software engineer managed the personalization algorithms or models integrated into the system. The framework acted as an intermediate step between game conceptualization and implementation; it was illustrated by developing and evaluating a proof of concept.

RESULTS

The proof of concept, a serious game for shoulder rehabilitation, was evaluated using simulations of heart rate and game scores to assess how personalization was achieved and whether the framework responded as expected. The simulations indicated the value of both real-time and offline personalization. The proof of concept illustrated how the interaction between different components worked and how the framework was used to simplify the design process.

CONCLUSIONS

The proposed framework for personalized serious games in health care identifies the responsibilities of the involved stakeholders in the design process, using 3 key questions for personalization. The framework focuses on the transferability of knowledge and reusability of personalization algorithms to simplify the design process of personalized serious games.

Virtual Reality for Motor and Cognitive Rehabilitation

Virtual Reality (VR) affords clinicians the ability to deliver safe, controlled, task-specific customised interventions that are enjoyable, motivating and engaging. Elements of training in VR comply with principles of learning implicated in new skill acquisition and re-learning skills post-neurological disorders. However, heterogeneity in the description of VR systems and the description and control of 'active' ingredients of interventions (like dosage, type of feedback, task specificity, etc.) have led to inconsistency in the synthesis and interpretation of evidence related to the effectiveness of VR-based interventions, particularly in post-stroke and Parkinson's Disease (PD) rehabilitation. This chapter attempts to describe VR interventions with respect to their compliance with principles of neurorehabilitation, with the goal of optimising interventions for effective training and facilitation of maximum functional recovery. This chapter also advocates using a uniform framework to describe VR systems to promote homogeneity in literature in order to help in the synthesis of evidence. An overview of the evidence revealed that VR systems are effective in mediating deficits in upper extremity, posture and gait function seen in people post-stroke and PD. Generally, interventions were more effective when they were delivered as an adjunct to conventional therapy and were customised for rehabilitation purposes, in addition to complying with principles of learning and neurorehabilitation. Although recent studies imply that their VR intervention is compliant with principles of learning, only a few explicitly describe how these principles are incorporated as 'active ingredients' of the intervention. Finally, VR interventions targeting community ambulation and cognitive rehabilitation are yet limited and therefore warrant attention.

Personalized Touch-Based Exergame System for Unilateral and Bilateral Rehabilitation Training

Background: Natural and intuitive interfaces that monitor and promote upper limb task-specific training need to be developed. This article presents the development and testing of a touch-based game system for training and assessment of unilateral (ULR) and bilateral (BLR) reaching movements. Interaction becomes intuitive and simple by introducing in-game touch and pressure onto virtual targets projected on a custom-made large touch panel. Materials and Methods: A custom-made App integrates exergames and a biomechanical model with advanced algorithms for movement analysis. It processes and manages data from a motion-tracking sensor and a large touch panel equipped with 1222 (26 × 47) piezoresistive sensors, including high-speed readout electronics and algorithms to measure touch points and contact forces during fingertip interaction. An experiment was conducted to evaluate the experience, motivation, and movements of healthy and stroke subjects when interacting with the proposed system. The panel height, dispersion of virtual targets, and required contact force were customized based on motor skills of each group of subjects. Results: Both groups of subjects showed high level of motivation and user experience when interacting with the virtual environments. Stroke subjects performed the task slower and traveled a similar path length than healthy subjects, but with shorter range of motion. The mechanical work and potential energy profiles of both groups are consistent with those achieved when reaching real objects. Conclusions: The proposed contact-based exergames are a feasible solution for performing natural and intuitive therapeutic ULR and BLR exercises. They elicit appropriate reaching movements and contact forces in healthy and stroke subjects. The spatial and temporal attributes of the proposed solution can be customized to influence the movement and energy expenditure of specific joints.

Serious Games Strategies With Cable-Driven Robots for Bimanual Rehabilitation: A Randomized Controlled Trial With Post-Stroke Patients

Cable-driven robots can be an ideal fit for performing post-stroke rehabilitation due to their specific features. For example, they have small and lightweight moving parts and a relatively large workspace. They also allow safe human-robot interactions and can be easily adapted to different patients and training protocols. However, the existing cable-driven robots are mostly unilateral devices that can allow only the rehabilitation of the most affected limb. This leaves unaddressed the rehabilitation of bimanual activities, which are predominant within the common Activities of Daily Living (ADL). Serious games can be integrated with cable-driven robots to further enhance their features by providing an interactive experience and by generating a high level of engagement in patients, while they can turn monotonous and repetitive therapy exercises into entertainment tasks. Additionally, serious game interfaces can collect detailed quantitative treatment information such as exercise time, velocities, and force, which can be very useful to monitor a patient's progress and adjust the treatment protocols. Given the above-mentioned strong advantages of both cable driven robots, bimanual rehabilitation and serious games, this paper proposes and discusses a combination of them, in particular, for performing bilateral/bimanual rehabilitation tasks. The main design characteristics are analyzed for implementing the design of both the hardware and software components. The hardware design consists of a specifically developed cable-driven robot. The software design consists of a specifically developed serious game for performing bimanual rehabilitation exercises. The developed software also includes BiEval. This specific software allows to quantitatively measure and assess the rehabilitation therapy effects. An experimental validation is reported with 15 healthy subjects and a RCT (Randomized Controlled Trial) has been performed with 10 post-stroke patients at the Physiotherapy's Clinic of the Federal University of Uberlândia (Minas Gerais, Brazil). The RCT results demonstrate the engineering feasibility and effectiveness of the proposed cable-driven robot in combination with the proposed BiEval software as a valuable tool to augment the conventional physiotherapy protocols and for providing reliable measurements of the patient's rehabilitation performance and progress. The clinical trial was approved by the Research Ethics Committee of the UFU (Brazil) under the CAAE N° 00914818.5.0000.5152 on plataformabrasil@saude.gov.br.

Effect of exercise mode on physical function and quality of life in breast cancer-related lymphedema: a randomized trial

PURPOSE

This study aimed to compare the effects of virtual reality (VR) training and resistance exercises training on lymphedema symptom severity as well as physical functioning and QoL in women with breast cancer-related lymphedema (BCRL).

METHODS

In a single blinded randomized trial, women diagnosed with unilateral BCRL were randomly divided into two groups: the Xbox Kinect group received VR Kinect-based games (n = 30) and resistance exercise group received resistance training (n = 30). In addition, both groups received complex decongestive physiotherapy (manual lymphatic drainage, compression bandages, skin care, and exercises). The intervention was conducted five sessions per week for 8 weeks. The outcome measures included excessive limb volume, visual analogue scale (VAS), the Disability of the Arm, Shoulder, and Hand (DASH) questionnaire, shoulder range of motion (ROM), shoulder muscles strength, hand grip strength, and Study Short-Form (SF-36). The outcomes were evaluated pre and post intervention (week 8).

RESULTS

Statistical significant differences were recorded in VAS (pain intensity), DASH, shoulder ROM (p < 0.001), bodily pain (p = 0.002), general health (p < 0.001), and vitality (p = 0.006) in favor of the Xbox Kinect group. However, there were statistically significant differences in shoulder flexion strength (p = 0.002), external rotation strength (p = 0.004), and abduction strength and handgrip strength (p < 0.001) in favor of the resistance exercise group.

CONCLUSIONS

The VR training was superior to resistance exercises training in BCRL management. The empirical findings support the VR as a new effective and encouraging intervention modality which can assist in improving physical functioning and quality of life in women with BCRL.

TRIAL REGISTRATION

This study is retrospectively registered at ClinicalTrials.gov (ID: NCT04724356).

Adaptive Rehabilitation Bots in Serious Games

In recent years, we have witnessed a growing adoption of serious games in telerehabilitation by taking advantage of advanced multimedia technologies such as motion capture and virtual reality devices. Current serious game solutions for telerehabilitation suffer form lack of personalization and adaptiveness to patients' needs and performance. This paper introduces "RehaBot", a framework for adaptive generation of personalized serious games in the context of remote rehabilitation, using 3D motion tracking and virtual reality environments. A personalized and versatile gaming platform with embedded virtual assistants, called "Rehab bots", is created. Utilizing these rehab bots, all workout session scenes will include a guide with various sets of motions to direct patients towards performing the prescribed exercises correctly. Furthermore, the rehab bots employ a robust technique to adjust the workout difficulty level in real-time to match the patients' performance. This technique correlates and matches the patterns of the precalculated motions with patients' motions to produce a highly engaging gamified workout experience. Moreover, multimodal insights are passed to the users pointing out the joints that did not perform as anticipated along with suggestions to improve the current performance. A clinical study was conducted on patients dealing with chronic neck pain to prove the usability and effectiveness of our adjunctive online physiotherapy solution. Ten participants used the serious gaming platform, while four participants performed the traditional procedure with an active program for neck pain relief, for two weeks (10 min, 10 sessions/2 weeks). Feasibility and user experience measures were collected, and the results of experiments show that patients found our game-based adaptive solution engaging and effective, and most of them could achieve high accuracy in performing the personalized prescribed therapies.

Application of AR and VR in hand rehabilitation: A systematic review

BACKGROUND

The human hand is the part of the body most frequently injured in work related accidents, accounting for a third of all accidents at work and often involving surgery and long periods of rehabilitation. Several applications of Augmented Reality (AR) and Virtual Reality (VR) have been used to improve the rehabilitation process. However, there is no sound evidence about the effectiveness of such applications nor the main drivers of therapeutic success.

OBJECTIVES

The objective of this study was to review the efficacy of AR and VR interventions for hand rehabilitation.

METHODS

A systematic search of publications was conducted in October 2019 in IEEE Xplore, Web of Science, Cochrane library, and PubMed databases. Search terms were: (1) video game or videogame, (2) hand, (3) rehabilitation or therapy and (4) VR or AR. Articles were included if (1) were written in English, (2) were about VR or AR applications, (3) were for hand rehabilitation, (4) the intervention had tests on at least ten patients with injuries or diseases which affected hand function and (5) the intervention had baseline or intergroup comparisons (AR or VR intervention group versus conventional physical therapy group). PRISMA protocol guidelines were followed to filter and assess the articles.

RESULTS

From the eight selected works, six showed improvements in the intervention group, and two no statistical differences between groups. We were able to identify motivators of patients' adherence, namely real-time feedback to the patients, challenge, and increased individualized difficulty. Automated tracking, easy integration in the home setting and the recording of accurate metrics may increase the scalability and facilitate healthcare professionals' assessments.

CONCLUSIONS

This systematic review provided advantages and drivers for the success of AR/VR application for hand rehabilitation. The available evidence suggests that patients can benefit from the use of AR or VR interventions for hand rehabilitation.

Is Xbox 360 Kinect-based virtual reality training as effective as standard physiotherapy in patients undergoing breast cancer surgery?

PURPOSE

Breast cancer surgery may be associated with pain and physical symptoms in the upper limbs. Functional impairment and pain-related avoidance of movement may further increase disability level. This study aimed to investigate the potential effects of early postoperative virtual reality (VR) therapy on pain, range of motion (ROM), muscle strength, functionality, and fear of movement.

METHODS

Forty women with breast cancer who had undergone unilateral mastectomy with axillary lymph node dissection and who were receiving adjuvant therapy were included in the study and randomly assigned to two groups: the Kinect-based rehabilitation group (KBRG) and the standardized physical therapy group (SPTG). The KBRG (n = 20) received VR therapy using Xbox Kinect-based games and the SPTG (n = 20) received standard physiotherapy. Study subjects were assessed at baseline and after the 6-week treatment. Outcome measures were pain (visual analogue scale), grip strength (dynamometer), functionality (disabilities of the arm shoulder and hand questionnaire), muscle strength (handheld dynamometer), ROM (digital goniometer), and fear of movement (Tampa kinesiophobia scale (TKS)).

RESULTS

Both groups detected significant changes in pain, ROM, muscle strength, grip strength, functionality, and TKS scores after the treatment (p < 0.01). Fear of movement was significantly improved in the KBRG and the SPTG displayed more improvement in functionality (p < 0.05). There were no differences in ROM, muscle strength, grip strength, and pain between the groups after the treatment (p > 0.05).

CONCLUSION

Kinect-based VR therapy resulted in significant outcomes that were comparable to those obtained under standard physiotherapy in the early postoperative phase in patients who had undergone breast cancer surgery.

TRIAL REGISTRATION

This study is registered at ClinicalTrials.gov ( ClinicalTrials.gov identifier: NCT03618433).