Feasibility of modified remotely monitored in-home gaming technology for improving hand function in adolescents with cerebral palsy

The application of virtual reality to home-based rehabilitation for children and adolescents with cerebral palsy: A systematic review and meta-analysis

BACKGROUND

Home-based rehabilitation enables children and families to participate in therapeutic activities built into their daily routines without the barriers of arrangement and transportation to facilities. Virtual reality is an emerging technology which has shown promising outcomes in rehabilitation.

PURPOSE

This systematic review aims to examine the feasibility and effects of virtual reality-enhanced home rehabilitation on Body functions and structures, Activity, and Participation outcomes in children and adolescents with cerebral palsy.

METHODS

Interventional studies were searched across five biomedical databases on November 26, 2022. Two independent reviewers conducted study selection, data extraction, and quality assessment. The Physiotherapy Evidence Database scale and National Institutes of Health Study Quality Assessment Tools were used to evaluate the quality of included studies. Meta-analysis was performed to examine the effects of the intervention.

RESULTS

Eighteen studies were included in this review. Home-based virtual reality rehabilitation appears feasible with effects on upper extremity and gross motor function, strength, bone density, cognition, balance, walking, daily activity performance, and participation. Meta-analyses revealed significant improvements in hand function (SMD = 0.41, p= .003), gross motor function (SMD = 0.56, p= .0002), and walking capacity (SMD = 0.44, p= .01) following home-based virtual reality intervention.

CONCLUSION

Home-based virtual reality may serve as an adjunct to conventional facility-based therapy to promote participation in therapeutic exercises and maximize rehabilitation outcomes. Further properly designed randomized controlled trials using valid and reliable outcome measures with adequately powered sample sizes are warranted to enhance the current body of evidence using home-based virtual reality in cerebral palsy rehabilitation.

Video games and disability-a risk and benefit analysis

Purpose

Over the past decades, video games have become a substantial part of the entertainment industry. While ubiquitous, video game participation remains low among people with disabilities amid potential negative effects. This article analyzes the risks and benefits that video games may present to individuals with disabilities.

Methodology

In this conceptual article, we explored the literature pertaining to video games and disability. To better understand the impact of video games on individuals with disabilities, we focused on the unique features of video games through the lens of the Self-Determination Theory.

Findings

Our findings show that individuals with disabilities are most at risk from excessive video game use, leading to increased aggression, sedentary behavior, and negative impact on academic performance. Identified benefits include promoting physical rehabilitation and psychological well-being, improving cognitive abilities and emotional regulation, and utility in promoting exercises, and managing chronic pain.

Originality

This article presents a number of strategies and resources to help guide individuals with disabilities, educators, practitioners, and researchers in maximizing the benefits of video games while controlling the risks.

Gamifying rehabilitation: MILORD platform as an upper limb motion rehabilitation service

Motor learning is based on the correct repetition of specific movements for their permanent storage in the central nervous system (CNS). Rehabilitation relies heavily on the repetition of specific movements, and game scenarios are ideal environments to build routines of repetitive exercises that have entertaining characteristics. In this respect, the gamification of the rehabilitation program, through the introduction of game-specific techniques and design concepts, has gained attention as a complementary or alternative to routine rehabilitation programs. A gamified rehabilitation program promises to gain the patient's attention, to reduce the monotony of the process and preserve motivation to attend, and to create virtual incentives through the game, toward maintaining compliance to the “prescribed” program. This is often achieved through goal-oriented tasks and real-time feedback in the form of points and other in-game rewards. This paper describes MILORD rehabilitation platform, an affordable technological solution, which aims to support health professionals and enable remote rehabilitation, while maintaining health service characteristics and monitoring. MILORD is an end-to-end platform that consists of an interactive computer game, utilizing a leap motion sensor, a centralized user management system, an analysis platform that processes the data generated by the game, and an analysis dashboard presenting a set of meaningful features that describe upper limb movement. Our solution facilitates the monitoring of the patients' progress and provides an alternative way to analyze hand movement. The system was tested with normal subjects and patients and experts to record user's experience, receive feedback, identify any problems, and understand the system's value in monitoring and support motion defect and progress. This small-scale study indicated the capacity of the analysis to quantify the movement in a meaningful way and express the differences between normal and pathological movement, and the user experience was positive with both patients and normal subjects.

Gamification in rehabilitation of metacarpal fracture using cost-effective end-user device: A randomized controlled trial

STUDY DESIGN

This is a two-group randomized controlled trial.

INTRODUCTION

Finger stiffness after treatment for metacarpal fractures often occurs due to poor compliance to the conventional rehabilitation programs. Gamification has shown success in improving adherence to and effectiveness of various therapies.

PURPOSE OF THE STUDY

The purpose of this study was to evaluate whether gamification, using cost-effective devices was comparable with conventional physiotherapy in improving hand functions and adherence to rehabilitation in metacarpal fractures.

METHODS

A 2-group randomized controlled trial involving 19 patients was conducted. Participants were randomized to a control (conventional physiotherapy, n = 10) or interventional group (gamification, n = 9). The grips strength and composite finger range of motion were measured at the baseline and each follow-up together with Patient-Rated Wrist and Hand Evaluation scores and compliance.

RESULTS

There were no significant differences on improvements of grip strength (means difference 24.38 vs 20.44, P = .289) and composite finger range of motion (means difference 50.50 vs 51.11, P = .886). However, the gamification group showed better results in Patient-Rated Wrist and Hand Evaluation (mean 0.44 vs 8.45, P = .038) and compliance (P < .05). No adverse events were reported.

DISCUSSION

Our results suggest that gamification using a cost-effective device demonstrated similar effectiveness as conventional physiotherapy in post-metacarpal fracture rehabilitation.

CONCLUSIONS

Gamification using a mobile device is an inexpensive and safe alternative to conventional physiotherapy for hand rehabilitation after metacarpal fractures. It effectively serves as a guide for future development of cost-effective technology-enhanced therapy.

Serious Gaming Technology in Upper Extremity Rehabilitation: Scoping Review

BACKGROUND

Serious gaming has increasingly gained attention as a potential new component in clinical practice. Specifically, its use in the rehabilitation of motor dysfunctions has been intensively researched during the past three decades.

OBJECTIVE

The aim of this scoping review was to evaluate the current role of serious games in upper extremity rehabilitation, and to identify common methods and practice as well as technology patterns. This objective was approached via the exploration of published research efforts over time.

METHODS

The literature search, using the PubMed and Scopus databases, included articles published from 1999 to 2019. The eligibility criteria were (i) any form of game-based arm rehabilitation; (ii) published in a peer-reviewed journal or conference; (iii) introduce a game in an electronic format; (iv) published in English; and (v) not a review, meta-analysis, or conference abstract. The search strategy identified 169 relevant articles.

RESULTS

The results indicated an increasing research trend in the domain of serious gaming deployment in upper extremity rehabilitation. Furthermore, differences regarding the number of publications and the game approach were noted between studies that used commercial devices in their rehabilitation systems and those that proposed a custom-made robotic arm, glove, or other devices for the connection and interaction with the game platform. A particularly relevant observation concerns the evaluation of the introduced systems. Although one-third of the studies evaluated their implementations with patients, in most cases, there is the need for a larger number of participants and better testing of the rehabilitation scheme efficiency over time. Most of the studies that included some form of assessment for the introduced rehabilitation game mentioned user experience as one of the factors considered for evaluation of the system. Besides user experience assessment, the most common evaluation method involving patients was the use of standard medical tests. Finally, a few studies attempted to extract game features to introduce quantitative measurements for the evaluation of patient improvement.

CONCLUSIONS

This paper presents an overview of a significant research topic and highlights the current state of the field. Despite extensive attempts for the development of gamified rehabilitation systems, there is no definite answer as to whether a serious game is a favorable means for upper extremity functionality improvement; however, this certainly constitutes a supplementary means for motivation. The development of a unified performance quantification framework and more extensive experiments could generate richer evidence and contribute toward this direction.

Hedonic and Utilitarian Motivations of Home Motion-Sensing Game Play Behavior in China: An Empirical Study

As an important branch of video games and the integration of emerging motion-sensing technology, home motion-sensing games cannot only bring hedonic entertainment but also promote utilitarian benefits including exercise and social interaction for people to improve their physical and psychological health. As one of the most populous countries in the world, China has the largest number of households in the world but quite a low home game penetration rate due to the 13 year game industry winter for international enterprises. Whether Chinese customers have the intention of using motion-sensing games to improve their health status in the home environment will directly determine the commercial potential of the relevant industry in the Chinese market. In order to understand the motives of users and explore the market possibility and prospects of the game industry, this study adopts empirical research and structural equation modeling to construct a motivation model of Chinese consumers toward motion-sensing gameplay behavior in the household environment. We distributed 515 questionnaires to conduct a survey; 427 valid responses have been received, and 203 data, which meet the inclusion criteria of the required game experience, have been analyzed by SPSS25.0 and AMOS25.0. A structural equation model for the gameplay motivation has been constructed. The result shows that the three functional motivators, exercise (Path efficient = 0.40, p < 0.01), entertainment (Path efficient = 0.27, p < 0.01), and social interaction (Path efficient = 0.36, p < 0.01) of home motion-sensing games have a significantly positive impact on the user's intention to play. Furthermore, the diversity and the time-and-place flexibility variables exert an important positive influence on the users' gameplay behavior through their effects on the three main functional motive variables. To sum up, (1) exercise, (2) entertainment, and (3) social interaction are the main functional motivations of the Chinese consumers' gameplay behaviors; (4) diversity and (5) time-and-place flexibility are the two main attribute motivators. The acceptance of Chinese users for home motion-sensing games remains positive and high. The motion-sensing game industry has broad market prospects in China through its potential in promoting consumer's wellness and health in the home environment.

Exploiting upper-limb functional principal components for human-like motion generation of anthropomorphic robots

BACKGROUND

Human-likeliness of robot movements is a key component to enable a safe and effective human-robot interaction, since it contributes to increase acceptance and motion predictability of robots that have to closely interact with people, e.g. for assistance and rehabilitation purposes. Several parameters have been used to quantify how much a robot behaves like a human, which encompass aspects related to both the robot appearance and motion. The latter point is fundamental to allow the operator to interpret robotic actions, and plan a meaningful reactions. While different approaches have been presented in literature, which aim at devising bio-aware control guidelines, a direct implementation of human actions for robot planning is not straightforward, still representing an open issue in robotics.

METHODS

We propose to embed a synergistic representation of human movements for robot motion generation. To do this, we recorded human upper-limb motions during daily living activities. We used functional Principal Component Analysis (fPCA) to extract principal motion patterns. We then formulated the planning problem by optimizing the weights of a reduced set of these components. For free-motions, our planning method results into a closed form solution which uses only one principal component. In case of obstacles, a numerical routine is proposed, incrementally enrolling principal components until the problem is solved with a suitable precision.

RESULTS

Results of fPCA show that more than 80% of the observed variance can be explained by only three functional components. The application of our method to different meaningful movements, with and without obstacles, show that our approach is able to generate complex motions with a very reduced number of functional components. We show that the first synergy alone accounts for the 96% of cost reduction and that three components are able to achieve a satisfactory motion reconstruction in all the considered cases.

CONCLUSIONS

In this work we moved from the analysis of human movements via fPCA characterization to the design of a novel human-like motion generation algorithm able to generate, efficiently and with a reduced set of basis elements, several complex movements in free space, both in free motion and in case of obstacle avoidance tasks.

Engaging children with cerebral palsy in interactive computer play-based motor therapies: theoretical perspectives

PURPOSE

To provide a theoretically grounded understanding of engagement in interactive computer play-based motor therapies by children with cerebral palsy in home settings.

METHODS

A motivational framework for engagement and its relationship with three contemporary theories (self-determination theory, expectancy-value theory, social cognitive theory of self-regulation) was overviewed. A scoping review was conducted to understand how engagement is influenced by features of the technology and intervention design that impact intrinsic and extrinsic motivation, child and parent values and expectancies, and the processes of self-regulation. Multiple reviewers screened and extracted data from 26 articles describing home-based clinical trials of interactive computer play-based motor interventions for children with cerebral palsy. A narrative synthesis framework was used for analysis.

RESULTS

Features of the technology and the intervention influence feelings of autonomy (e.g., personalization), competence (e.g., calibration), and relatedness (e.g., social play, virtual therapist/coach). There may be multiple and differently valued goals in interactive computer play-based interventions (e.g., game- and therapy-focused) that, if disconnected or unmet, negatively impact engagement. Multiplayer interactions, real-time feedback and progress tracking provide information that influences self-regulation and engagement over time.

CONCLUSIONS

Optimizing engagement in interactive computer play-based motor interventions requires closer alignment with client-led values/goals; design of technologies and interventions that sustain intrinsic motivation; and feedback that informs/builds self-efficacy. Implications for rehabilitation The decision to prescribe an interactive computer play-based motor intervention should be guided by client-led goals and an informed understanding of the capacity of the interactive computer play-based intervention to meet individual client values/expectancies. Sustaining intrinsic motivation in interactive computer play-based motor therapies is greatly influenced by features of the technology (e.g., calibration, feedback, personalization) and the intervention (e.g., interactions with therapists, social play). Increased effort should be directed towards ensuring that interactive computer play-based interventions and technologies reward and reinforce efforts towards therapy goals.

Contrasting performance between physically active and sedentary older people playing exergames

The increase in life expectancy associated with the increase in chronological age and less active people helps in the appearance of chronic and degenerative diseases. The encouragement of physical exercises contributes to older people abandoning sedentarism and preventing such diseases. Exergame is a promising alternative, for making exercise a pleasurable activity.In this study, we compared the performance of physically active older people with sedentary older people in exergames.Participants were 83 older adults over 65 years of age, of both sexes, divided into 2 physically active older people (AG) and sedentary older people (CG) groups. The participants performed a task through an exergame called "MoviLetrando" that uses the score, number of hits, number of omissions, and an average time of hits as an evaluation. A characterization questionnaire was applied, with information about sex, age, marital status, economic class, self-rated health, time of use of electronic games, a questionnaire on the practice of physical activity, and the Brunel Mood Scale.There was a higher exergame score in AG than in CG (P = .003), in the number of correct answers (P = .012). The number of omissions was lower in AG than in CG (P = .023). The mean time of correct answers was lower in AG than in CG (P = .013). The regression analysis revealed a significant finding F (3, 82) = 11.06, P < .001 and showed a prediction ability of 26.9% (r = .269). Three variables remained significantly associated with the score: physical activity was marginally significant (β = .19, P = .06), age (β = -.403, P < .001), depression (β = -.212, P = .028).Physically active older people perform better when compared with the sedentary older people. Age, depression, and physical activity influence the performance in exergame.

Analysis of motor performance in individuals with cerebral palsy using a non-immersive virtual reality task - a pilot study

PURPOSE

To evaluate the performance improvement of individuals with hemiparesis cerebral palsy (CP) using a virtual task.

PARTICIPANTS AND METHODS

Twenty individuals were selected and distributed into two groups. The experimental group (CP group) comprised ten individuals with a medical diagnosis of CP, and ten individuals with typical development (sex- and age-matched) composed the control group (TD group). Both groups followed the same intervention protocol, which included a virtual coincident timing task: the participants performed upper limb movements in front of a computer's webcam and interacted with the task with the aim of virtually intercepting spheres that fell in four rows following the rhythm of a pre-selected song during an 8-minute period. To verify the influence on a real task, pre- and posttests were performed in a similar task, but with physical contact (using the spacebar on the keyboard of a computer). To analyze the data, we evaluated the variable, constant, and absolute errors during the task and in the pre- and posttests.

RESULTS

The results showed that there was an improvement in performance between the pre- and posttests; that is, after practicing the task in an environment without physical contact, there was a performance improvement in posttests in the real task, but only for the CP group. Moreover, there were significant differences in precision and accuracy between the two groups, with worse performance in the CP group.

CONCLUSION

Individuals with CP presented better performance in the real task after practice in a virtual reality task, albeit with worse performance compared with individuals with TD. This is an interesting result that supports the possible use of virtual tasks for the rehabilitation of individuals with CP.

Efficacy of different interaction devices using non-immersive virtual tasks in individuals with Amyotrophic Lateral Sclerosis: a cross-sectional randomized trial

Background

Amyotrophic Lateral Sclerosis (ALS) is a rapid progressive neurodegenerative disease, characterized by a selective loss of motor neurons, brain stem and spinal cord which leads to deterioration of motor abilities. Devices that promote interaction with tasks on computers can enhance performance and lead to greater independence and utilization of technology.

Objective

To evaluate performance on a computer task in individuals with ALS using three different commonly used non-immersive devices.

Method

Thirty individuals with ALS (18 men and 12 women, mean age 59 years, range 44–74 years) with a mean score of 26, (minimum score of 14 and maximum 41) on the Revised Amyotrophic Lateral Sclerosis Functional Rating Scale (ALSFRS-R) and 30 healthy controls matched for age and gender, participated. All participants were randomly divided into three groups, each using a different device system (motion tracking, finger motion control or touchscreen) to perform three task phases (acquisition, retention and transfer).

Results

Both the ALS and control group (CG) showed better performance on the computer task when using the touchscreen device, but there was limited transfer of performance onto the task performed on the Finger Motion control or motion tracking. However, we found that using the motion tracking device led to transfer of performance to the touchscreen.

Conclusion

This study presents novel and important findings when selecting interaction devices for individuals with ALS to access technology by demonstrating immediate performance benefits of using a touchscreen device, such as improvement of motor skills. There were possible transferable skills obtained when using virtual systems which may allow flexibility and enable individuals to maintain performance overtime.

Trial registration

Registration name: Virtual Task in Amyotrophic Lateral Sclerosis; Registration number: NCT03113630; retrospectively registered on 04/13/2017. Date of enrolment of the first participant to the trial: 02/02/2016.

In-Home Delivery of Constraint-Induced Movement Therapy via Virtual Reality Gaming

Purpose

People with chronic hemiparesis are frequently dissatisfied with the recovery of their hand and arm, yet many lack access to effective treatments. Constraint-induced movement therapy (CI therapy) effectively increases arm function and spontaneous use in persons with chronic hemiparesis. The purpose of this study was to determine the feasibility and measure safety and outcomes of an in-home model of delivering CI therapy using a custom, avatar-based virtual reality game.

Methods

Seventeen individuals with chronic hemiparesis participated in this pretest/posttest quasi-experimental design study. The 10-day intervention had three components: 1) high-repetition motor practice using virtual reality gaming; 2) constraint of the stronger arm via a padded restraint mitt; and 3) a transfer package to reinforce arm use. Feasibility of the intervention was evaluated through comparison to traditional CI therapy and through participants' subjective responses. The primary outcome measures were the Wolf Motor Function Test (WMFT) and the Motor Activity Log quality of movement scale (MAL-QOM).

Results

On average, participants completed 17.2 ± 8 hours and 19,436 repetitions of motor practice. No adverse events were reported. Of 7 feasibility criteria, 4 were met. WMFT rate and MAL-QOM increased, with effect size (Cohen's d) of 1.5 and 1.1, respectively.

Conclusions

This model of delivering CI therapy using a custom, avatar-based virtual reality game was feasible, well received, and showed preliminary evidence of being a safe intervention to use in the home for persons with chronic hemiparesis.

Feasibility of Pediatric Game-Based Neurorehabilitation Using Telehealth Technologies: A Case Report

This case report is the first in a series of reports designed to determine the feasibility of implementing game-based neurorehabilitation using telehealth technologies (GbN+TT) for children with cerebral palsy, evaluate the responsiveness of relevant outcome measures to changes in motor impairment and activity participation after intervention, and identify technological challenges associated with implementation of GbN+TT. The participant completed more than 56 hr of game-based neurorehabilitation over 8 wk using the Timocco platform in his home. The primary measures of motor impairment (Bruininks-Oseretsky Test of Motor Proficiency, Second Edition) and function (Pediatric Motor Activity Log) were both sensitive to change. Results indicate that it is feasible to administer GbN+TT to a child with cerebral palsy and monitor outcomes using standardized assessments.

Videogames as Therapy

There is a long history of using videogames in a therapeutic capacity including rehabilitation for stroke patients, people with traumatic brain injuries, burns victims, wheelchair users, Erb's palsy sufferers, children undergoing chemotherapy, children with muscular dystrophy, autistic children and individuals looking to overcome real-life challenges (including symptoms of depression) and boost their wellbeing (including boosting life satisfaction, self-efficacy and social support). This paper briefly and selectively examines a number of areas including: (1) videogames as physiotherapy and occupational therapy, (2) videogames as distractors in the role of pain management, (3) videogames and cognitive rehabilitation, (4) videogames and the development of social and communication skills among the learning disabled, (5) videogames and impulsivity/attention deficit disorders, (6) videogames and therapeutic benefits in the elderly, (7) videogames in psychotherapeutic settings, (8) videogames and health care, (9) videogames and anxiety disorders, and (10) videogames and psychological wellbeing. It is concluded that there has been considerable success when games are specifically designed to address a specific problem or to teach a certain skill. However, generalizability outside the game-playing situation remains an important consideration.

Serious games for upper limb rehabilitation: a systematic review

The aim of this research is to carry out a systematic review of the use of technological gaming platforms with serious games in the upper limb rehabilitation of patients with neuromotor disorders. Through a systematic review, the first two authors defined the inclusion criteria and extracted the data, resulting in 38 studies collected from B-On, PubMed and Medline. Ninety-two per cent of the selected articles were published since 2010. This review documents 35 different gaming platforms types. Twenty-one of the 38 articles included in this review conducted a clinical trial and of those only eight report improvements in the target population following the use of the games and platforms. This review concludes that a new paradigm is emerging in the rehabilitation field, characterized by the systematic use of technological gaming platforms with serious games in/for rehabilitation. The use of this approach seems to be beneficial. However, to facilitate the full integration of these platforms, it is necessary to conduct more research in this area, explore new approaches and carry out in-depth clinical studies into the benefits of these platforms. Implications for rehabilitation This review states that the use serious games and gaming platforms for upper limb rehabilitation are starting a new paradigm in the rehabilitation. For a full integration of this technologies in the rehabilitation field more studies are needed.

Effects of Nintendo Wii-Fit® video games on balance in children with mild cerebral palsy

BACKGROUND

This study compared the effects of Nintendo Wii-Fit^® balance-based video games and conventional balance training in children with mild cerebral palsy (CP).

METHODS

This randomized controlled trial involved 30 ambulatory pediatric patients (aged 5-18 years) with CP. Participants were randomized to either conventional balance training (control group) or to Wii-Fit balance-based video games training (Wii group). Both group received neuro-developmental treatment (NDT) during 24 sessions. In addition, while the control group received conventional balance training in each session, the Wii group played Nintendo Wii Fit games such as ski slalom, tightrope walk and soccer heading on balance board. Primary outcomes were Functional Reach Test (forward and sideways), Sit-to-Stand Test and Timed Get up and Go Test. Nintendo Wii Fit balance, age and game scores, 10 m walk test, 10-step climbing test and Wee-Functional Independence Measure (Wee FIM) were secondary outcomes.

RESULTS

After the treatment, changes in balance scores and independence level in activities of daily living were significant (P < 0.05) in both groups. Statistically significant improvements were found in the Wii-based game group compared with the control group in all balance tests and total Wee FIM score (P < 0.05).

CONCLUSION

Wii-fit balance-based video games are better at improving both static and performance-related balance parameters when combined with NDT treatment in children with mild CP.

Using Free Internet Videogames in Upper Extremity Motor Training for Children with Cerebral Palsy

Movement therapy is one type of upper extremity intervention for children with cerebral palsy (CP) to improve function. It requires high-intensity, repetitive and task-specific training. Tedium and lack of motivation are substantial barriers to completing the training. An approach to overcome these barriers is to couple the movement therapy with videogames. This investigation: (1) tested the feasibility of delivering a free Internet videogame upper extremity motor intervention to four children with CP (aged 8–17 years) with mild to moderate limitations to upper limb function; and (2) determined the level of intrinsic motivation during the intervention. The intervention used free Internet videogames in conjunction with the Microsoft Kinect motion sensor and the Flexible Action and Articulated Skeleton Toolkit software (FAAST) software. Results indicated that the intervention could be successfully delivered in the laboratory and the home, and pre- and post- impairment, function and performance assessments were possible. Results also indicated a high level of motivation among the participants. It was concluded that the use of inexpensive hardware and software in conjunction with free Internet videogames has the potential to be very motivating in helping to improve the upper extremity abilities of children with CP. Future work should include results from additional participants and from a control group in a randomized controlled trial to establish efficacy.

AULA-Advanced Virtual Reality Tool for the Assessment of Attention: Normative Study in Spain

OBJECTIVE

The present study describes the obtention of normative data for the AULA test, a virtual reality tool designed to evaluate attention problems, especially in children and adolescents.

METHOD

The normative sample comprised 1,272 participants (48.2% female) with an age range from 6 to 16 years (M = 10.25, SD = 2.83). The AULA test administered to them shows both visual and auditory stimuli, while randomized distractors of ecological nature appear progressively.

RESULTS

Variables provided by AULA were clustered in different categories for their posterior analysis. Differences by age and gender were analyzed, resulting in 14 groups, 7 per sex group. Differences between visual and auditory attention were also obtained.

CONCLUSION

Obtained normative data are relevant for the use of AULA for evaluating attention in Spanish children and adolescents in a more ecological way. Further studies will be needed to determine sensitivity and specificity of AULA to measure attention in different clinical populations. (J. of Att. Dis. 2016; 20(6) 542-568).

Development of an EMG-ACC-Based Upper Limb Rehabilitation Training System

This paper focuses on the development of an upper limb rehabilitation training system designed for use by children with cerebral palsy (CP). It attempts to meet the requirements of in-home training by taking advantage of the combination of portable accelerometers (ACC) and surface electromyography (SEMG) sensors worn on the upper limb to capture functional movements. In the proposed system, the EMG-ACC acquisition device works essentially as wireless game controller, and three rehabilitation games were designed for improving upper limb motor function under a clinician's guidance. The games were developed on the Android platform based on a physical engine called Box2D. The results of a system performance test demonstrated that the developed games can respond to the upper limb actions within 210 ms. Positive questionnaire feedbacks from twenty CP subjects who participated in the game test verified both the feasibility and usability of the system. Results of a long-term game training conducted with three CP subjects demonstrated that CP patients could improve in their game performance through repetitive training, and persistent training was needed to improve and enhance the rehabilitation effect. According to our experimental results, the novel multi-feedback SEMG-ACC-based user interface improved the users' initiative and performance in rehabilitation training.

Preparing a neuropediatric upper limb exergame rehabilitation system for home-use: a feasibility study

Background

Home-based, computer-enhanced therapy of hand and arm function can complement conventional interventions and increase the amount and intensity of training, without interfering too much with family routines. The objective of the present study was to investigate the feasibility and usability of the new portable version of the YouGrabber® system (YouRehab AG, Zurich, Switzerland) in the home setting.

Methods

Fifteen families of children (7 girls, mean age: 11.3y) with neuromotor disorders and affected upper limbs participated. They received instructions and took the system home to train for 2 weeks. After returning it, they answered questions about usability, motivation, and their general opinion of the system (Visual Analogue Scale; 0 indicating worst score, 100 indicating best score; ≤30 not satisfied, 31–69 average, ≥70 satisfied). Furthermore, total pure playtime and number of training sessions were quantified. To prove the usability of the system, number and sort of support requests were logged.

Results

The usability of the system was considered average to satisfying (mean 60.1–93.1). The lowest score was given for the occurrence of technical errors. Parents had to motivate their children to start (mean 66.5) and continue (mean 68.5) with the training. But in general, parents estimated the therapeutic benefit as high (mean 73.1) and the whole system as very good (mean 87.4). Children played on average 7 times during the 2 weeks; total pure playtime was 185 ± 45 min. Especially at the beginning of the trial, systems were very error-prone. Fortunately, we, or the company, solved most problems before the patients took the systems home. Nevertheless, 10 of 15 families contacted us at least once because of technical problems.

Conclusions

Despite that the YouGrabber® is a promising and highly accepted training tool for home-use, currently, it is still error-prone, and the requested support exceeds the support that can be provided by clinical therapists. A technically more robust system, combined with additional attractive games, likely results in higher patient motivation and better compliance. This would reduce the need for parents to motivate their children extrinsically and allow for clinical trials to investigate the effectiveness of the system.

Trial registration

ClinicalTrials.gov NCT02368223

Electronic supplementary material

The online version of this article (doi:10.1186/s12984-016-0141-x) contains supplementary material, which is available to authorized users.

The design and evaluation of an activity monitoring user interface for people with stroke

Usability is an important topic in the field of telerehabilitation research. Older users with disabilities in particular, present age-related and disability-related challenges that should be accommodated for in the design of a user interface for a telerehabilitation system. This paper describes the design, implementation, and assessment of a telerehabilitation system user interface that tries to maximize usability for an elderly user who has experienced a stroke. An Internet-connected Nintendo(®) Wii™ gaming system is selected as a hardware platform, and a server and website are implemented to process and display the feedback information. The usability of the interface is assessed with a trial consisting of 18 subjects: 10 healthy Doctor of Physical Therapy students and 8 people with a stroke. Results show similar levels of usability and high satisfaction with the gaming system interface from both groups of subjects.

Implicit guidance to stable performance in a rhythmic perceptual-motor skill

Feedback about error or reward is regarded essential for aiding learners to acquire a perceptual-motor skill. Yet, when a task has redundancy and the mapping between execution and performance outcome is unknown, simple error feedback does not suffice in guiding the learner toward the optimal solutions. The present study developed and tested a new means of implicitly guiding learners to acquire a perceptual-motor skill, rhythmically bouncing a ball on a racket. Due to its rhythmic nature, this task affords dynamically stable solutions that are robust to small errors and noise, a strategy that is independent from actively correcting error. Based on the task model implemented in a virtual environment, a time-shift manipulation was designed to shift the range of ball-racket contacts that achieved dynamically stable solutions. In two experiments, subjects practiced with this manipulation that guided them to impact the ball with more negative racket accelerations, the indicator for the strategy with dynamic stability. Subjects who practiced under normal conditions took longer time to acquire this strategy, although error measures were identical between the control and experimental groups. Unlike in many other haptic guidance or adaptation studies, the experimental groups not only learned, but also maintained the stable solution after the manipulation was removed. These results are a first demonstration that more subtle ways to guide the learner to better performance are needed especially in tasks with redundancy, where error feedback may not be sufficient.

Validity and reliability of Kinect skeleton for measuring shoulder joint angles: a feasibility study

OBJECTIVE

To test the reliability and validity of shoulder joint angle measurements from the Microsoft Kinect™ for virtual rehabilitation.

DESIGN

Test-retest reliability and concurrent validity, feasibility study.

SETTING

Motion analysis laboratory.

PARTICIPANTS

A convenience sample of 10 healthy adults.

METHODS

Shoulder joint angle was assessed in four static poses, two trials for each pose, using: (1) the Kinect; (2) a three-dimensional motion analysis system; and (3) a clinical goniometer. All poses were captured with the Kinect from the frontal view. The two poses of shoulder flexion were also captured with the Kinect from the sagittal view.

MAIN OUTCOME MEASURES

Absolute and relative test-retest reliability of the Kinect for the measurement of shoulder angle was determined in each pose with intraclass correlation coefficients (ICCs), standard error of the measure and minimal detectable change. The 95% limits of agreement (LOA) between the Kinect and the standard methods for measuring shoulder angle were computed to determine concurrent validity.

RESULTS

While the Kinect provided to be highly reliable (ICC 0.76-0.98) for measuring shoulder angle from the frontal view, the 95% LOA between the Kinect and the two measurement standards were greater than ±5° in all poses for both views.

CONCLUSIONS

Before the Kinect is used to measure movements for virtual rehabilitation applications, it is imperative to understand its limitations in precision and accuracy for the measurement of specific joint motions.

Therapeutic Uses of Active Videogames: A Systematic Review

BACKGROUND

Active videogames (AVGs) may be useful for promoting physical activity for therapeutic uses, including for balance, rehabilitation, and management of illness or disease. The literature from 64 peer-reviewed publications that assessed health outcomes of AVGs for therapeutic purposes was synthesized.

MATERIALS AND METHODS

PubMed, Medline, and PyschInfo were queried for original studies related to the use of AVGs to improve physical outcomes in patients who were ill or undergoing rehabilitation related to balance, burn treatment, cancer, cerebral palsy, Down's syndrome, extremity dysfunction or amputation, hospitalization, lupus, Parkinson's disease, spinal injury, or stroke. The following inclusion criteria were used: (1) human subjects; (2) English language; (3) not duplicates; (4) new empirical data; and (5) tests an AVG, including commercially available or custom-designed. Studies were included regardless of participants' age or the study design.

RESULTS AND LIMITATIONS

Overall, the vast majority of studies demonstrated promising results for improved health outcomes related to therapy, including significantly greater or comparable effects of AVG play versus usual care. However, many studies were pilot trials with small, homogeneous samples, and many studies lacked a control or comparison group. Some trials tested multiweek or multimonth interventions, although many used a single bout of gameplay, and few included follow-up assessments to test sustainability of improved health.

CONCLUSIONS AND IMPLICATIONS

AVGs were acceptable and enjoyable to the populations examined and appear as a promising tool for balance, rehabilitation, and illness management. Future research directions and implications for clinicians are discussed.

Transfer of motor learning from virtual to natural environments in individuals with cerebral palsy

With the growing accessibility of computer-assisted technology, rehabilitation programs for individuals with cerebral palsy (CP) increasingly use virtual reality environments to enhance motor practice. Thus, it is important to examine whether performance improvements in the virtual environment generalize to the natural environment. To examine this issue, we had 64 individuals, 32 of which were individuals with CP and 32 typically developing individuals, practice two coincidence-timing tasks. In the more tangible button-press task, the individuals were required to 'intercept' a falling virtual object at the moment it reached the interception point by pressing a key. In the more abstract, less tangible task, they were instructed to 'intercept' the virtual object by making a hand movement in a virtual environment. The results showed that individuals with CP timed less accurate than typically developing individuals, especially for the more abstract task in the virtual environment. The individuals with CP did-as did their typically developing peers-improve coincidence timing with practice on both tasks. Importantly, however, these improvements were specific to the practice environment; there was no transfer of learning. It is concluded that the implementation of virtual environments for motor rehabilitation in individuals with CP should not be taken for granted but needs to be considered carefully.

Preliminary evaluation of SensHand V1 in assessing motor skills performance in Parkinson disease

Nowadays, the increasing old population 65+ as well as the pace imposed by work activities lead to a high number of people that have particular injuries for limbs. In addition to persistent or temporary disabilities related to accidental injuries we must take into account that part of the population suffers from motor deficits of the hands due to stroke or diseases of various clinical nature. The most recurrent technological solutions to measure the rehabilitation or skill motor performance of the hand are glove-based devices, able to faithfully capture the movements of the hand and fingers. This paper presents a system for hand motion analysis based on 9-axis complete inertial modules and dedicated microcontroller which are fixed on fingers and forearm. The technological solution presented is able to track the patients' hand motions in real-time and then to send data through wireless communication reducing the clutter and the disadvantages of a glove equipped with sensors through a different technological structure. The device proposed has been tested in the study of Parkinson's disease.

Effect of virtual reality on upper extremity function in children with cerebral palsy: a meta-analysis

PURPOSE

To systematically examine the effect of virtual reality (VR) on upper extremity (UE) function in children with cerebral palsy (CP) and assess the association among VR effects and children's characteristics and an intervention protocol.

METHOD

A systematic literature search was conducted in PubMed, CINAHL, Cochrane, and PsycINFO up to June 2013. Research studies involving children with CP that used VR as the intervention method and UE outcome measures were included.

RESULTS

The search yielded 14 research articles, including 3 randomized controlled trials and 11 case series. Overall, VR provided a strong effect size (d = 1.00) when comparing pre- and postintervention. In subgroup analyses, younger children receiving home-based or laboratory-based VR and using an engineer-built VR system showed better improvement.

CONCLUSIONS AND IMPLICATIONS

Virtual reality is a viable tool to improve UE function in children with CP. However, a more vigorous research design is needed to make a conclusive recommendation.

Markerless motion capture and measurement of hand kinematics: validation and application to home-based upper limb rehabilitation

Dynamic movements of the hand, fingers, and thumb are difficult to measure due to the versatility and complexity of movement inherent in function. An innovative approach to measuring hand kinematics is proposed and validated. The proposed system utilizes the Microsoft Kinect and goes beyond gesture recognition to develop a validated measurement technique of finger kinematics. The proposed system adopted landmark definition (validated through ground truth estimation against assessors) and grip classification algorithms, including kinematic definitions (validated against a laboratory-based motion capture system). The results of the validation show 78% accuracy when identifying specific markerless landmarks. In addition, comparative data with a previously validated kinematic measurement technique show accuracy of MCP ± 10° (average absolute error (AAE) = 2.4°), PIP ± 12° (AAE = 4.8°), and DIP ± 11° (AAE = 4.8°). These results are notably better than clinically based alternative manual measurement techniques. The ability to measure hand movements, and therefore functional dexterity, without interfering with underlying composite movements, is the paramount objective to any bespoke measurement system. The proposed system is the first validated markerless measurement system using the Microsoft Kinect that is capable of measuring finger joint kinematics. It is suitable for home-based motion capture for the hand and, therefore, achieves this objective.

Robotics and gaming to improve ankle strength, motor control, and function in children with cerebral palsy--a case study series

The objective of this study was to investigate the feasibility of game-based robotic training of the ankle in children with cerebral palsy (CP). The design was a case study, 12 weeks intervention, with no follow-up. The setting was a university research laboratory. The participants were a referred sample of three children with cerebral palsy, age 7-12, all male. All completed the intervention. Participants trained on the Rutgers Ankle CP system for 36 rehabilitation sessions (12 weeks, three times/week), playing two custom virtual reality games. The games were played while participants were seated, and trained one ankle at-a-time for strength, motor control, and coordination. The primary study outcome measures were for impairment (DF/PF torques, DF initial contact angle and gait speed), function (GMFM), and quality of life (Peds QL). Secondary outcome measures relate to game performance (game scores as reflective of ankle motor control and endurance). Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. Game performance improved in both games during the intervention. This feasibility study supports the assumption that game-based robotic training of the ankle benefits gait in children with CP. Game technology is appropriate for the age group and was well accepted by the participants. Additional studies are needed however, to quantify the level of benefit and compare the approach presented here to traditional methods of therapy.

A fully immersive set-up for remote interaction and neurorehabilitation based on virtual body ownership

Although telerehabilitation systems represent one of the most technologically appealing clinical solutions for the immediate future, they still present limitations that prevent their standardization. Here we propose an integrated approach that includes three key and novel factors: (a) fully immersive virtual environments, including virtual body representation and ownership; (b) multimodal interaction with remote people and virtual objects including haptic interaction; and (c) a physical representation of the patient at the hospital through embodiment agents (e.g., as a physical robot). The importance of secure and rapid communication between the nodes is also stressed and an example implemented solution is described. Finally, we discuss the proposed approach with reference to the existing literature and systems.

Long-term hand tele-rehabilitation on the PlayStation 3: benefits and challenges

Rehabilitation interventions for the hand have shown benefits for children with Hemiplegia due to cerebral palsy or traumatic brain injury. Longer interventions are facilitated if training is provided in the patient's home, due to easier access to care and reduced impact on school or work activities. Providing remote rehabilitation over lengthy periods of time has however its own challenges. This paper presents two pediatric patients with hemiplegia, who practiced virtual hand rehabilitation games using a modified PlayStation 3 and 5DT sensing gloves. Despite severe initial hand spasticity, and occasional technology shortcomings, the subjects practiced for about 14 months, and 6 months, respectively. Game performance data for the second patient is presented. Follow-up evaluations 14 months from the removal of the PlayStation 3 from the home of the child with cerebral palsy showed that the patient had good retention in terms of grasp strength, hand function and bone health. Challenges of long-term home tele-rehabilitation are also discussed.

Complex versus simple ankle movement training in stroke using telerehabilitation: a randomized controlled trial

BACKGROUND

Telerehabilitation allows rehabilitative training to continue remotely after discharge from acute care and can include complex tasks known to create rich conditions for neural change.

OBJECTIVES

The purposes of this study were: (1) to explore the feasibility of using telerehabilitation to improve ankle dorsiflexion during the swing phase of gait in people with stroke and (2) to compare complex versus simple movements of the ankle in promoting behavioral change and brain reorganization.

DESIGN

This study was a pilot randomized controlled trial.

SETTING

Training was done in the participant's home. Testing was done in separate research labs involving functional magnetic resonance imaging (fMRI) and multi-camera gait analysis.

PATIENTS

Sixteen participants with chronic stroke and impaired ankle dorsiflexion were assigned randomly to receive 4 weeks of telerehabilitation of the paretic ankle.

INTERVENTION

Participants received either computerized complex movement training (track group) or simple movement training (move group).

MEASUREMENTS

Behavioral changes were measured with the 10-m walk test and gait analysis using a motion capture system. Brain reorganization was measured with ankle tracking during fMRI.

RESULTS

Dorsiflexion during gait was significantly larger in the track group compared with the move group. For fMRI, although the volume, percent volume, and intensity of cortical activation failed to show significant changes, the frequency count of the number of participants showing an increase versus a decrease in these values from pretest to posttest measurements was significantly different between the 2 groups, with the track group decreasing and the move group increasing.

LIMITATIONS

Limitations of this study were that no follow-up test was conducted and that a small sample size was used.

CONCLUSIONS

The results suggest that telerehabilitation, emphasizing complex task training with the paretic limb, is feasible and can be effective in promoting further dorsiflexion in people with chronic stroke.

Defining the active ingredients of interactive computer play interventions for children with neuromotor impairments: a scoping review

Rehabilitation researchers who investigate complex interventions are challenged to describe the "active ingredients" of their interventions: the reason(s) why a treatment is expected to be effective. Interactive Computer Play (ICP) is an emerging complex intervention in rehabilitation practice and research. The purpose of this scoping review is to identify the active ingredients of ICP interventions that are designed to improve motor outcomes in children with neuromotor impairments. Eleven potential active ingredients were identified with the following foci: ICP system or game properties; intervention effects on the user; and therapist roles. However, few studies explicitly evaluate the impact of particular ingredients on outcomes. Identification of active ingredients in ICP interventions can inform trial design and clinical decision-making. Research and clinical practice will benefit from studies that utilize a framework such as motor learning theory to guide hypotheses and measurement of the active ingredients of complex interventions.

Maintained hand function and forearm bone health 14 months after an in-home virtual-reality videogame hand telerehabilitation intervention in an adolescent with hemiplegic cerebral palsy

Virtual reality videogames can be used to motivate rehabilitation, and telerehabilitation can be used to improve access to rehabilitation. These uses of technology to improve health outcomes are a burgeoning area of rehabilitation research. So far, there is a lack of reports of long-term outcomes of these types of interventions. The authors report a 15-year-old boy with hemiplegic cerebral palsy and epilepsy because of presumed perinatal stroke who improved his plegic hand function and increased his plegic forearm bone health during a 14-month virtual reality videogame hand telerehabilitation intervention. A total of 14 months after the intervention ended, repeat evaluation demonstrated maintenance of both increased hand function and forearm bone health. The implications of this work for the future of rehabilitation in children with neurological disabilities are discussed in this article.

Ankle control and strength training for children with cerebral palsy using the Rutgers Ankle CP: a case study

The purpose of the study described here was to develop and feasibility test the Rutgers Ankle CP, aimed at ankle strengthening and improved control for children with cerebral palsy (CP). The system was an upgrade in hardware (new foot attachment, new robot controller) and software (new games and programming language) of the earlier Rutgers Ankle in order to permit training of children with CP. The new Rutgers Ankle CP was used to train ankle strength and motor control in a 7 year old boy with CP during 36 rehabilitation sessions (12 weeks, 3 times/week). Assessments for impairment, function and quality of life were taken before and after training. Results indicated improvements in both strength and motor control. Gait function improved substantially in ankle kinematics, speed and endurance. Overall function (GMFM) indicated improvements that were typical of other ankle strength training programs. Quality of life increased beyond what would be considered a minimal clinical important difference. While these results are only for a single participant, they are very encouraging toward improving the function and quality of life of children with cerebral palsy. Further research with a larger number of participants is planned.