Neurorehabilitation using the virtual reality based Rehabilitation Gaming System: methodology, design, psychometrics, usability and validation

<p>Abstract</p> <p>Background</p> <p>Stroke is a frequent cause of adult disability that can lead to enduring impairments. However, given the life-long plasticity of the brain one could assume that recovery could be facilitated by the harnessing of mechanisms underlying neuronal reorganization. Currently it is not clear how this reorganization can be mobilized. Novel technology based neurorehabilitation techniques hold promise to address this issue. Here we describe a Virtual Reality (VR) based system, the Rehabilitation Gaming System (RGS) that is based on a number of hypotheses on the neuronal mechanisms underlying recovery, the structure of training and the role of individualization. We investigate the psychometrics of the RGS in stroke patients and healthy controls.</p> <p>Methods</p> <p>We describe the key components of the RGS and the psychometrics of one rehabilitation scenario called Spheroids. We performed trials with 21 acute/subacute stroke patients and 20 healthy controls to study the effect of the training parameters on task performance. This allowed us to develop a Personalized Training Module (PTM) for online adjustment of task difficulty. In addition, we studied task transfer between physical and virtual environments. Finally, we assessed the usability and acceptance of the RGS as a rehabilitation tool.</p> <p>Results</p> <p>We show that the PTM implemented in RGS allows us to effectively adjust the difficulty and the parameters of the task to the user by capturing specific features of the movements of the arms. The results reported here also show a consistent transfer of movement kinematics between physical and virtual tasks. Moreover, our usability assessment shows that the RGS is highly accepted by stroke patients as a rehabilitation tool.</p> <p>Conclusions</p> <p>We introduce a novel VR based paradigm for neurorehabilitation, RGS, which combines specific rehabilitative principles with a psychometric evaluation to provide a personalized and automated training. Our results show that the RGS effectively adjusts to the individual features of the user, allowing for an unsupervised deployment of individualized rehabilitation protocols.</p

An integrative framework for tailoring virtual reality based motor rehabilitation after stroke

Stroke is a leading cause of life-lasting motor impairments, undermining the quality of life of stroke survivors and their families, and representing a major chal lenge for a world population that is ageing at a dramatic rate. Important technologi cal developments and neuroscientific discoveries have contributed to a better under standing of stroke recovery. Virtual Reality (VR) arises as a powerful tool because it allows merging contributions from engineering, human computer interaction, reha bilitation medicine and neuroscience to propose novel and more effective paradigms for motor rehabilitation. However, despite evidence of the benefits of these novel training paradigms, most of them still rely on the choice of particular technologi cal solutions tailored to specific subsets of patients. Here we present an integrative framework that utilizes concepts of human computer confluence to 1) enable VR neu rorehabilitation through interface technologies, making VR rehabilitation paradigms accessible to wide populations of patients, and 2) create VR training environments that allow the personalization of training to address the individual needs of stroke patients. The use of these features is demonstrated in pilot studies using VR training environments in different configurations: as an online low-cost version, with a myo electric robotic orthosis, and in a neurofeedback paradigm. Finally, we argue about the need of coupling VR approaches and neurocomputational modelling to further study stroke and its recovery process, aiding on the design of optimal rehabilitation programs tailored to the requirements of each user.info:eu-repo/semantics/publishedVersio

Virtual reality with customized positive stimuli in a cognitive-motor rehabilitation task: a feasibility study with subacute stroke patients with mild cognitive impairment

Virtual Reality applications for integrated cognitive and motor stroke rehabilitation show promise for providing more comprehensive rehabilitation programs. However, we are still missing evidence on its impact in comparison with standard rehabilitation, particularly in patients with cognitive impairment. Additionally, little is known on how specific stimuli in the virtual environment affect task performance and its consequence on recovery. Here we investigate the impact in stroke recovery of a virtual cognitive-motor task customized with positive stimuli, in comparison to standard rehabilitation. The positive stimuli were images based on individual preferences, and self-selected music (half of the sessions). 13 participants in the subacute stage of stroke, with cognitive and motor deficits, were allocated to one of two groups (VR, Control). Motor and cognitive outcomes were assessed at end of treatment (4-6 weeks) and at a 4-week followup. Both groups showed significant improvements over time in functional ability during task performance, but without changes in motor impairment. Cognitive outcomes were modest in both groups. For participants in the VR group, the score in the task was significantly higher in sessions with music. There were no statistical differences between groups at end of treatment and follow-up. The impact of VR therapy was lower than in similar studies with stroke patients without cognitive deficits. This study is a first step towards understanding how VR could be shaped to address the particular needs of this population.info:eu-repo/semantics/publishedVersio

Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation

Background: The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming. Methods: We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire. Results: In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p <.001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p=.074), significantly shorter travel distance (p <.001), higher movement efficiency (p <.001) and higher performance scores (p <.001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance. Conclusions: Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation

Impact of game mode in multi-user serious games for upper limb rehabilitation: a within-person randomized trial on engagement and social involvement

Background: Serious games have been increasingly used for motor rehabilitation. However, it is not well known how different game features can be used to impact specific skills properly. Here, we study how the mode (competitive, co-active, collaborative) in which a multi-user game is presented impacts engagement and social involvement. Methods: We collected data from 20 pairs of community-dwelling older adults (71.5 ± 8.7 years) in a study following a within-persons design. The participants performed a two-player upper limb rehabilitation game with three conditions (Competitive, Co-active, and Collaborative modes). Engagement and social involvement were assessed through the Core Module and Social Presence Module, respectively, from the Game Experience Questionnaire. To infer the impact of personality and cognitive function, users answered the International Personality Item Pool (short version) and the Montreal Cognitive Assessment, respectively. Results: Results show that the Collaborative game mode promotes more social involvement when compared to Competitive and Co-active modes. This result is mostly explained by those participants with higher cognitive skills, and those that are more extrovert. Extrovert participants feel more empathy and are behaviorally more involved when playing the Collaborative mode. Also, the Collaborative mode is shown to be appropriate to promote interaction with participants that previously had a distant relationship, while the Competitive mode seems to be more beneficial to promote empathy between players with a closer relationship. Conclusions: The Collaborative game mode elicited significantly higher social involvement in terms of Empathy, Positive Affect, and Behavioral Involvement. Hence, this game mode seems to be the most adequate choice to be used in multiplayer rehabilitation settings, where social interaction is intended.info:eu-repo/semantics/publishedVersio

The use of game modes to promote engagement and social involvement in multi-user serious games: a within-person randomized trial with stroke survivors

Serious games are promising for stroke rehabilitation, with studies showing a positive impact on reducing motor and cognitive defcits. However, most of the evidence is in the context of single-user rehabilitation, and little is known concerning the impact in multi-user settings. This study evaluates the impact that diferent game modes can have on engagement and social involvement during a two-user game. Specifcally, we want to under stand the benefts of game modalities based on competition, co-activation, and collaboration and analyze the infu ence of diferent motor and cognitive defcits and personality traits. Methods: We developed a two-player setup—using tangible objects and a large screen interactive table—for upper limb rehabilitation purposes. We implemented a game that, while keeping the same basic mechanics, can be played in the three diferent modes (Competitive, Co-active, and Collaborative). We ran a within-person randomized study with 21 stroke survivors that were paired and played the game in its three versions. We used the Game Experi ence Questionnaire—Core Module to assess engagement and the Social Presence Module to assess Social Involve ment. For personality, motor, and cognitive function, users answered the International Personality Item Pool (short version), Fugl-Meyer Assessment—Upper Extremity, Modifed Ashworth Scale, and Montreal Cognitive Assessment, respectively. Results: The Collaborative mode promoted signifcantly more Behavioral Involvement. The Competitive mode pro moted more Flow and Challenge than the Co-active mode with participants with better cognitive performance, with low extraversion, or with higher motor skills. Participants with higher cognitive defcits reported more Competence with the Co-active mode. Conclusions: Our results indicate that, for multi-user motor rehabilitation settings, the collaborative mode is the more appropriate gaming approach to promote social involvement, showing a high potential for increasing adher ence and efectiveness of therapy. Additionally, we show that a player’s motor and cognitive ability and personality should be considered when designing personalized tasks for multiplayer settings.info:eu-repo/semantics/publishedVersio

The benefits of emotional stimuli in a virtual reality cognitive and motor rehabilitation task: assessing the impact of positive, negative and neutral stimuli with stroke patients

VR-based methods for stroke rehabilitation have mainly focused on motor rehabilitation, but there is increasing interest towards the integration of cognitive training for providing more ecologically valid solutions. However, more studies are needed, especially in the definition of which type of content should be used in the design of these tools. One possibility is the use of emotional stimuli, which are known to enhance attentional processes. According to the Socio-emotional Selectivity Theory, as people age, this emotional salience arises for positive and neutral, but not for negative stimuli. Conversely, negative stimuli can be better remembered. In this study, we investigated the impact of using emotional stimuli with positive, negative and neutral valence in a VR cognitive and motor attention task. Ten stroke patients participated in a within subjects experiment with four conditions based on the type of stimuli: abstract (control condition), positive, negative and neutral. The main task consisted of finding a target stimulus, shown for only two seconds, among fourteen neutral distractors. Eye movements were recorded with an eye-tracking system to investigate differences between conditions and in search patterns. Subsequently, a recall task took place and the patients had to identify all the target images among a valence-matched number of distractors. Our results corroborate the attention salience effect of positive and neutral stimuli in the VR task performance. Although we found no statistically significant differences between conditions in the recall task, there was a trend for recalling more negative images. This negative advantage comes at the expense of significantly more wrongly identified images/false memories for negative stimuli. Finally, we performed an analysis in which we relate performance scores with well-established cognitive assessment instruments, which supportsG the use of this approach both for assessment and rehabilitation purposes.info:eu-repo/semantics/publishedVersio

Virtual reality based upper extremity rehabilitation following stroke: a review

In the last decade there have been major developments in the creation of interactive virtual scenarios for the rehabilitation of motor deficits following stroke. Virtual reality technology is arising as a promising tool to diagnose, monitor and induce functional recovery after lesions to the nervous system. This evidence has grown in the last few years, as effort has been made to develop virtual scenarios that are built on the knowledge of mechanisms of recovery. In this paper we review the state of the art virtual reality techniques for rehabilitation of functionality of the upper extremities following stroke. We refer to some of the main systems that have been developed within different rehabilitative approaches such as learning by imitation, reinforced feedback, haptic feedback, augmented practice and repetition, video capture virtual reality, exoskeletons, mental practice, action observation and execution, and others. The major findings of these studies show that virtual reality technologies will become a more and more essential ingredient in the treatment of stroke and other disorders of the nervous system.info:eu-repo/semantics/publishedVersio

Using a multi-task adaptive vr system for upper limb rehabilitation in the acute phase of stroke

Nowadays, stroke has become one the main causes of adult disability leading to life-lasting effects, including motor and cognitive deficits. Here we explore the benefits of the use of virtual reality (VR) for the rehabilitation of motor deficits following stroke. We have developed the Rehabilitation Gaming System (RGS), a VR-based apparatus designed for the treatment of the upper extremities. The RGS is a multi-level adaptive system that provides a task oriented training of graded complexity that is online adjusted to the capabilities of the patients. We show results from an ongoing study that evaluates the impact of this system on the recovery of patients in the acute phase of stroke (n=14). The results suggest that the system induces a sustained improvement during treatment, with observed benefits in the performance of activities of daily living.info:eu-repo/semantics/publishedVersio

Physiological responses during performance within a virtual scenario for the rehabilitation of motor deficits

Real-time physiological feedback can be used to modulate a virtual reality (VR) experience. It is not obvious, however, which parameters are most effective in achieving this such as heart rate variability and or the electrodermal response. Here we address this question by assessing the impact of the events generated by a VR based rehabilitation system on the affective state of human users. We show how the Rehabilitation Gaming System (RGS), a tool developed for the rehabilitation of motor deficits following stroke, can be enhanced using the online monitoring of bodily changes that are not under direct voluntary control. We show specific effects of the RGS on the autonomic nervous system and we propose how to use these for the modulation of the emotional state of the subject and performance.info:eu-repo/semantics/publishedVersio