Home-based exergames to improve cognitive function in Multiple Sclerosis: the EXTREMUS Study ​

Background. Motor and cognitive dysfunctions are common and disabling features in multiple sclerosis (MS) that remain challenging to be treated. Exergaming is an emerging tool in neurorehabilitation, which promotes motor functions and fitness level. Evidence in general population and in other neurological conditions suggests that exergames may be beneficial also for cognitive functions, as playing action video games requires the engagement of high-level domains for visuo-motor integration and spatial attention. Objective. To test if home-based exergaming is not inferior to cognitive rehabilitation delivered by a software application (app) for mobile devices and both interventions are superior to a placebo-analogue (sham) cognitive intervention. The hypothesis is that exergames offer a comprehensive approach to improve both motor and cognitive domains. Methods. This is a multicenter, randomized, sham-controlled, single blind, parallel arm study. People with MS (pwMS) will be randomized in a 1:1:1 ratio to receive 1) an 8-week home-based training with exergames, specifically with Nintendo Wii (intervention of interest) or 2) adaptive COGNI-TRAcK (comparator intervention) or 3) sham COGNI-TRAcK (placebo-analogue intervention). Assessments will be conducted at study enrolment (baseline), at the end of the 8-week intervention period (immediate post-training, Week 8) and after 16 weeks from randomization (post-training follow-up, Week 16). At each point in the assessment, Brief International Cognitive Assessment for MS (BICAMS) and the Stroop Color Word Test (SCWT). In addition, pwMS were assessed with the 29-item Multiple Sclerosis Impact Scale (MSIS-29), the 21-item Modified Fatigue Impact Scale (MFIS-21), the 2-Minute Walking Test (2MWT), the Timed Up&Go test (TUG) and by a static posturography under single- (ST) and dual-task (DT) conditions were conducted. Results. Sixty-nine pwMS were assessed for eligibility in this pre-planned interim analysis; of these, 47 were randomized to the three treatment groups. The three treatment groups were comparable in terms of demographic and clinical characteristics at baseline (all p values >0.2). Preliminary analyses show statistically significant results between the SHAM group and the ADAPTIVE group (p=0.04) for the Symbol Digit Modalities Test (SDMT), the information processing speed assessment test that is part of BICAMS; the improvement observed between the EXERGAMES group and the SHAM group, did not reach statistical significance (p=0.06). TUG among the three groups showed statistically significant improvement between the EXERGAMES group and the SHAM group (p=0.01) and the ADAPTIVE group (p<0.001). Regarding fatigue, statistically significant results emerged between the SHAM group and the ADAPTIVE group (p=0.04) and between the ADAPTIVE group and the EXERGAMES group (p=0.01). In the EXERGAMES group, there was an improvement in balance measured by posturography the ST and DT conditions (p=0.01 and p=0.02). Discussion. Although this is only preliminary data, some interesting results emerged from the study. First, both COGNI-TRAcK and Nintendo Wii-treated patients experienced improvements in SDMT compared to the SHAM group. In addition, the study found that patients undergoing home rehabilitation with the Nintendo Wii also achieved improvements in the motor domain. Second, it appears that rehabilitation training with exergames can bring improvements in some specific domains of QoL and fatigue. The results obtained for fatigue in people with MS show that exergames are significantly effective in improving after the intervention, compared with the other groups. These results indicate that rehabilitation with exergames, which requires simultaneous physical and cognitive effort on the part of the patient, promotes not only the strengthening of motor functions, but also the efficiency of brain networks, particularly those dedicated to attention

Custom-designed motion-based games for older adults: a review of literature in human-computer interaction

Many older adults, particularly persons living in senior residences and care homes, lead sedentary lifestyles, which reduces their life expectancy. Motion-based video games encourage physical activity and might be an opportunity for these adults to remain active and engaged; however, research efforts in the field have frequently focused on younger audiences and little is known about the requirements and benefits of motion-based games for elderly players. In this paper, we present an overview of motion-based video games and other interactive technologies for older adults. First, we summarize existing approaches towards the definition of motion-based video games – often referred to as exergames – and suggest a categorization of motion-based applications into active video games, exergames, and augmented sports. Second, we use this scheme to classify case studies addressing design efforts particularly directed towards older adults. Third, we analyze these case studies with a focus on potential target audiences, benefits, challenges in their deployment, and future design opportunities to investigate whether motion-based video games can be applied to encourage physical activity among older adults. In this context, special attention is paid to evaluation routines and their implications regarding the deployment of such games in the daily lives of older adults. The results show that many case studies examine isolated aspects of motion-based game design for older adults, and despite the broad range of issues in motion-based interaction for older adults covered by the sum of all research projects, there appears to be a disconnect between laboratory-based research and the deployment of motion-based video games in the daily lives of senior citizens. Our literature review suggests that despite research results suggesting various benefits of motion-based play for older adults, most work in the field of game design for senior citizens has focused on the implementation of accessible user interfaces, and that little is known about the long-term deployment of video games for this audience, which is a crucial step if these games are to be implemented in activity programs of senior residences, care homes, or in therapy

Clinical Decision Support Systems with Game-based Environments, Monitoring Symptoms of Parkinson’s Disease with Exergames

Parkinson’s Disease (PD) is a malady caused by progressive neuronal degeneration, deriving in several physical and cognitive symptoms that worsen with time. Like many other chronic diseases, it requires constant monitoring to perform medication and therapeutic adjustments. This is due to the significant variability in PD symptomatology and progress between patients. At the moment, this monitoring requires substantial participation from caregivers and numerous clinic visits. Personal diaries and questionnaires are used as data sources for medication and therapeutic adjustments. The subjectivity in these data sources leads to suboptimal clinical decisions. Therefore, more objective data sources are required to better monitor the progress of individual PD patients. A potential contribution towards more objective monitoring of PD is clinical decision support systems. These systems employ sensors and classification techniques to provide caregivers with objective information for their decision-making. This leads to more objective assessments of patient improvement or deterioration, resulting in better adjusted medication and therapeutic plans. Hereby, the need to encourage patients to actively and regularly provide data for remote monitoring remains a significant challenge. To address this challenge, the goal of this thesis is to combine clinical decision support systems with game-based environments. More specifically, serious games in the form of exergames, active video games that involve physical exercise, shall be used to deliver objective data for PD monitoring and therapy. Exergames increase engagement while combining physical and cognitive tasks. This combination, known as dual-tasking, has been proven to improve rehabilitation outcomes in PD: recent randomized clinical trials on exergame-based rehabilitation in PD show improvements in clinical outcomes that are equal or superior to those of traditional rehabilitation. In this thesis, we present an exergame-based clinical decision support system model to monitor symptoms of PD. This model provides both objective information on PD symptoms and an engaging environment for the patients. The model is elaborated, prototypically implemented and validated in the context of two of the most prominent symptoms of PD: (1) balance and gait, as well as (2) hand tremor and slowness of movement (bradykinesia). While balance and gait affections increase the risk of falling, hand tremors and bradykinesia affect hand dexterity. We employ Wii Balance Boards and Leap Motion sensors, and digitalize aspects of current clinical standards used to assess PD symptoms. In addition, we present two dual-tasking exergames: PDDanceCity for balance and gait, and PDPuzzleTable for tremor and bradykinesia. We evaluate the capability of our system for assessing the risk of falling and the severity of tremor in comparison with clinical standards. We also explore the statistical significance and effect size of the data we collect from PD patients and healthy controls. We demonstrate that the presented approach can predict an increased risk of falling and estimate tremor severity. Also, the target population shows a good acceptance of PDDanceCity and PDPuzzleTable. In summary, our results indicate a clear feasibility to implement this system for PD. Nevertheless, long-term randomized clinical trials are required to evaluate the potential of PDDanceCity and PDPuzzleTable for physical and cognitive rehabilitation effects

Visualization and Interaction Technologies in Serious and Exergames for Cognitive Assessment and Training: A Survey on Available Solutions and Their Validation

Exergames and serious games, based on standard personal computers, mobile devices and gaming consoles or on novel immersive Virtual and Augmented Reality techniques, have become popular in the last few years and are now applied in various research fields, among which cognitive assessment and training of heterogeneous target populations. Moreover, the adoption of Web based solutions together with the integration of Artificial Intelligence and Machine Learning algorithms could bring countless advantages, both for the patients and the clinical personnel, as allowing the early detection of some pathological conditions, improving the efficacy and adherence to rehabilitation processes, through the personalisation of training sessions, and optimizing the allocation of resources by the healthcare system. The current work proposes a systematic survey of existing solutions in the field of cognitive assessment and training. We evaluate the visualization and interaction technologies commonly adopted and the measures taken to fulfil the need of the pathological target populations. Moreover, we analyze how implemented solutions are validated, i.e. The chosen experimental designs, data collection and analysis. Finally, we consider the availability of the applications and raw data to the large community of researchers and medical professionals and the actual application of proposed solutions in the standard clinical practice. Despite the potential of these technologies, research is still at an early stage. Although the recent release of accessible immersive virtual reality headsets and the increasing interest on vision-based techniques for tracking body and hands movements, many studies still rely on non-immersive virtual reality (67.2%), mainly mobile and personal computers, and standard gaming tools for interactions (41.5%). Finally, we highlight that although the interest of research community in this field is increasingly higher, the sharing of dataset (10.6%) and implemented applications (3.8%) should be promoted and the number of healthcare structures which have successfully introduced the new technological approaches in the treatment of their host patients is limited (10.2%)

Use of serious games with older adults: systematic literature review

The aim of this paper is to qualitatively synthesise literature on empirical research into video games and older adults. A total of 108 studies were analysed, with the participation of 15,902 individuals aged over 60. The framework of Search, Appraisal, Synthesis, and Analysis (SALSA) was used, with screening by three independent reviewers and phrase searching and combining search terms. The results indicate a majority of studies with a quantitative approach conducted in the European context in which a total of 125 scales were identified for the assessment of different geriatric aspects related to domains for the improvement of physical health and functional quality, improvement of cognitive, psychological and mental health, and improvement of physical and cognitive functions from a combined approach.info:eu-repo/semantics/publishedVersio

New techniques for neuro-rehabilitation: Transcranial Electric Stimulation and Virtual Reality

Recovery of motor and cognitive performances after a neurological illness remains a significant challenge for rehabilitation specialists. The traditional rehabilitative interventions are usually delivered using a multidisciplinary approach, whose results are not always satisfactory. These limitations in functional recovery have led researchers to consider alternative approaches. The hypothesis of providing new therapeutic possibilities in the different patients treated is, as a rehabilitator, very rewarding and represents a challenge for the future. The application of simple and low-cost techniques, defined by the literature as "unconventional" or “novel”, can provide new ideas not only in the field of research but above all of application in clinical reality.A suitable approach to improve the rehabilitation outcome is to utilize these novel rehabilitation techniques that act as a substitute or an addition to the traditional ones. In this context, some recent approaches have been proposed that might increase the effectiveness of a traditional treatment. Among them, two techniques have been demonstrated to be very promising, namely non-invasive brain stimulation (NIBS) and Virtual Reality (VR).In light of the foregoing, my thesis has been divided into two main lines of research, namely: a) the study of the effects of transcranial direct current stimulation (tDCS) in different neurological conditions; b) the application of VR (used alone or combined with tDCS) in the treatment of some neurocognitive disorders. A semi-immersive VR tool (ReMOVES system) has been used as a user-friendly platform providing activities based on exergames