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Robotic-assisted serious game for motor and cognitive post-stroke rehabilitation
... The initial study of [44] had explored the neurorehabilitation capabilities of an MIT-Manus based system, finding no negative consequences. This was further proved in the work of Heins et al. [45], that presented ROBiGAME, playable with a REAplan controller for improving stroke patients' motor and cognitive functionality. A feasibility study conducted with two stroke patients observed that patients loved playing the game. ...
... For instance, one critical feature is automatically detecting when the patient or user of the system is experiencing discomfort [123]. Ergonomics of the devices used in the system is another area of concern, with many of the works, such as [45], [46], [59], [66] reporting on the users' affinity with the system and ease of use. The system's stability is also a significant concern, given that the peripherals involved in the system are in very close proximity with the users. ...
... Adaptation of Automated Rehabilitation Systems: As reported in [45], [46], [58], [59], users show a strong affinity for automated systems, despite some concerns about higher costs. Some works report on the needs and perspectives of the therapists involved in the deployment of these systems. ...
Post-stroke therapy restores lost skills. Traditionally, patients are supported by skilled therapists who monitor their progress and evaluate the program’s effectiveness. Due to a shortage of qualified therapists, rehabilitation facilities are both expensive and inadequate. Furthermore, evaluations may be subjective and prone to errors. These limitations motivate the researchers to devise automated systems with minimal human intervention, therapist-like assessment, and broader outreach. This article reviews seminal works from 2013 onwards, qualitatively and quantitatively adapting the PRISMA approach to examine the potential of robot-assisted, virtual reality-based rehabilitation and automated assessments through data-driven learning. Extensive experimentation on KIMORE and UI-PRMD datasets reveal high agreement between automated methods and therapists. Our investigation shows that deep learning with spatio-temporal skeleton data and dynamic attention outperforms others, with an RMSE as low as 0.55. Fully automated rehabilitation is still in development, but, being an active research topic, it could hasten objective assessment and improve outreach.
... Success in a particular level was measured by either completion of a task or in a more challenging setup, within a certain time limit as well as indicated in the study by Carabeo et al. [50]. The use of unpredictability in the gameplay [51] and distractions [52] were also mentioned as a means to not only increase engagement but also challenge the patient. It should be noted that unfamiliarity with the equipment or the game itself also results in patients not clearing the first stage at the first or initial few attempts. ...
... All but one of the studies in our review put emphasis on managing the difficulty level of the stroke rehabilitation games. Burke et al. [9,18], Lange et al. [49], Heins et al. [52] are some of the articles that mentioned that choosing the difficulty level for game design is an important decision and that the challenge or difficulty level of the game should match player's abilities in order to maintain their engagement. ...
... Hence, it can be said that feedback is a type of reply to the question asked by the player while playing game [54]. Further, at least three studies explicitly mentioned the use of colour coding feedback strategies to represent success and failure in the gameplay (such as through green and red respectively), amongst them [42,52,53]. ...
Aims and Objectives: Stroke is the main cause of long-term disabilit and happens mostly in the older population. Stroke affected patients experience either of the cognitive, visual or motor losses and recovery requires time and patience as they have to do physical exercises every day and at times repetitively. There are various types of stroke rehabilitation exercises focussing on technological solutions that include therapies performed using games. Motion-based games are popular in encouraging participants to perform repetitive tasks without being getting bored. Therefore, in this study, we have explored studies that included the use of games for stroke rehabilitation to understand the design principles and characteristics of the games used for these purposes.
Method: A number of medical respositories were searched for relevant articles in a window of 2008-2018. 18 studies were chosen for the scoping review depending on the inclusion criteria, and design principles used in these studies are analysed and evaluated.
Results and Conclusion: We present main findings from our review concerning the attributes of existing games for stroke rehabilitation such as meaningful play, handling of failures, emphasising challenge, and the value of feedback. We conclude with a list of design recommendations that future serious game developers can consider while designing interfaces for stroke patients.
• Implications for Rehabilitation
• This review exhibits that the usage of gaming technologies is a very effective interactive mechanism for stroke based rehabilitation.
• Further our review also shows that serious games provide an avenue and opportunity for customized and highly contextualized gameplay
• Our review also suggests that effective features to incorporate into serious games for rehabilitation includes; facilitating challenge and recovery from errors.
... A previous study suggested an interest to rehabilitate motor and cognitive impairments together to put patients in real-world settings (Cameirao, Faria, Paulino, Alves, & Bermudez, 2016). According to these observations, the ROBiGAME project was set up to develop a serious game on a rehabilitation robot in order to rehabilitate simultaneously UL motor and cognitive impairments among stroke patients (Heins et al., 2017). The ROBiGAME's design is shown in Fig. 1 (Heins et al., 2017). ...
... According to these observations, the ROBiGAME project was set up to develop a serious game on a rehabilitation robot in order to rehabilitate simultaneously UL motor and cognitive impairments among stroke patients (Heins et al., 2017). The ROBiGAME's design is shown in Fig. 1 (Heins et al., 2017). During the serious game (e.g., for the target pointing exercise), the robot allows for assistance as needed based on the patient's performance. ...
... Patients were recruited in the Cliniques universitaires Saint-Luc (Belgium). To be included in the study, healthy subjects had to be aged between fifty and eighty years (to match with the mean age of stroke patients), they had to be able to understand instructions and they should not present with (Heins et al., 2017). The goal is to adapt game difficulty to individual patient's performance. ...
BACKGROUND: ROBiGAME project aims to implement serious games on robots to rehabilitate upper limb (UL) in stroke patients. The serious game characteristics (target position, level of assistance/resistance, level of force) are adapted based on the patient's assessment before and continuously during the game (measuring UL working area, kinematics and muscle strength).
OBJECTIVE: To develop an UL robotic motor assessment protocol to configure the serious game.
METHODS: 32 healthy subjects and 20 stroke patients participated in the study. Subjects were clinically assessed (UL length and isometric force) and using a robot. The robot assessment consisted of the patient's UL working area (WA), the UL isometric and isokinetic force in three directions and the UL kinematics during a pointing task toward targets placed at different distances.
RESULTS: The WA and the UL isometric force were moderately to highly correlated with clinical measures (respectively ρ= 0.52; p = 0.003, ρ= 0.68-0.73; p < 0.001). Ratios between the UL isokinetic force generated on three directions were established. The velocity and straightness indexes of all subjects increased when subjects had to reach to targets placed more distantly (r= 0.82-0.90; ρ= 0.86-0.90 respectively; p < 0.001).
CONCLUSIONS: This protocol can be integrated into a serious game in order to continuously configure the game characteristics to patient's performance.
... In fact, algorithms that allow to adapt and regulate serious games' difficulty according to the patient performance and recovery exist. 427 As a perspective, we could therefore imagine that, when patients use the ARAT-VR and BBT-VR to assess their upper-limb activity and manual dexterity, algorithms would automatically use these scores to adapt and tailor serious games' difficulty to their level of motor recovery. ...
... show that individuals mostly adhere to serious games and enjoy the playability of these interventions. 427,472 More specifically, for immersive virtual reality, several works reveal that head-mounted displays are generally well supported by individuals with stroke and older adults. 473,474 On the clinician's side, virtual reality is generally well-accepted although opinions seem more nuanced. ...
... In line with the Yerkes-Dodson law, there is also evidence indicating that to maintain participants' motivation, the level of difficulty should be optimally balanced, neither too hard nor too easy [39]. To achieve this optimal balance, research suggests that game difficulty should be adjustable and tailored to individual participants' motor and cognitive performance [29,40,41]. Research supports the idea that self-adaptive training, where the difficulty is adjusted based on real-time performance, can optimize learning [42]. ...
Background
Despite their potential, the use of serious games within immersive virtual reality (iVR) for enhancing motor skills in older adults remains relatively unexplored. In this study, we developed a self-adaptive serious game in iVR called REAsmash-iVR. This game involves swiftly locating and striking a digital mole presented with various distractors.
Objective
This short-term longitudinal pre-post study aims to evaluate REAsmash-iVR’s efficacy in promoting motor learning in older adults. Specifically, we seek to determine the transfer and retention of motor learning achieved through REAsmash-iVR to other iVR tasks.
Methods
A total of 20 older adults participated in the study, engaging with REAsmash-iVR over 7 consecutive days. The evaluation included iVR tests such as KinematicsVR and a VR adaptation of the Box and Block Test (BBT-VR). KinematicsVR tasks included drawing straight lines and circles as fast and as accurately as possible, while BBT-VR required participants to move digital cubes as quickly as possible within 60 seconds. Assessments were conducted before and after the intervention, with a follow-up at 1 week post intervention. The primary outcome focused on evaluating the impact of REAsmash-iVR on speed-accuracy trade-off during KinematicsVR tasks. Secondary outcomes included analyzing movement smoothness, measured by spectral arc length, and BBT-VR scores.
Results
Results revealed significant improvements in speed-accuracy trade-off post intervention compared to that before the intervention, with notable retention of skills for straight lines (t19=5.46; P<.001; Cohen d=1.13) and circle drawing (t19=3.84; P=.001; Cohen d=0.787). Likewise, there was a significant enhancement in spectral arc length, particularly for circle drawing (χ²2=11.2; P=.004; ε2=0.23), but not for straight-line drawing (χ²2=2.1; P=.35; ε2=0.003). Additionally, participants demonstrated transfer with significant improvement (q=5.26; P<.001; Cohen r=0.678) and retention (q=6.82; P<.001; Cohen r=0.880) in BBT-VR skills.
Conclusions
These findings provide perspectives for the use of iVR to improve motor learning in older adults through delivering self-adaptive serious games targeting motor and cognitive functions.
Trial Registration
ClinicalTrials.gov NCT04694833; https://clinicaltrials.gov/study/NCT04694833
... These games often comply with a range of characteristics that are not typical of commercial entertainment and off-the-shelf games [17], and are designed to be interactive, meaningful and challenging [19]. Some of these can even update the game difficulty according to the user's performance and handle failure with relevant cues and feedbacks [20]. Typically, serious games have the potential to respect key neurorehabilitation and motor learning principles [21,22], thus favoring neuroplasticity [23]. ...
Purpose: This meta-analysis aimed to quantify the effect of serious games over conventional therapy on upper-limb activity, balance, gait, fatigue, and cognitive functions in people with multiple sclerosis. Materials and methods: Search strategies were developed for PubMed, Embase, Cochrane Library, and Scopus. Studies were selected if participants were adults with multiple sclerosis; the intervention consisted of a virtual reality serious game-based program; the control group received conventional therapy; outcomes included upper limb activity, balance, gait, fatigue, or cognitive functions; and used a randomized controlled trial design. Data were synthesized using a standardized mean difference with a random-effects model. Results: From 2532 studies, seventeen trials were selected (n = 740). Overall, serious games programs effect on upper limb activity, gait, verbal memory, verbal fluency and attention seemed neutral. Balance functions appeared to be improved by semi-immersive virtual reality serious games (SMD = 0.48;95%CI = 0.12-0.84;p = 0.01;I 2 =0%), fatigue by treadmill serious games (SMD = 0.80;95%CI = 0.40-1.20;p < 0.001) and visuo-spatial memory by semi-immersive virtual reality general cognitive serious games (SMD = 0.35;95%CI = 0.04-0.65;p = 0.03;I 2 =0%). Conclusion: This review suggests, with a very-low-to-low certainty of evidence, that while some specific serious games may improve balance, fatigue and visuo-spatial memory, their overall effect on upper limb activity, gait, and other cognitive functions appears neutral. h IMPLICATIONS FOR REHABILITATION • Serious games may enhance engagement and adherence to rehabilitation by making the process more interactive and motivating. • Their design, which often includes adaptive difficulty levels and relevant feedback, can provide a tailored and dynamic rehabilitation experience for people with multiple sclerosis. • Some specific serious games programs involving the use of semi-and non-immersive virtual reality devices seem to lead to benefits in balance, fatigue and visuo-spatial memory. • Serious games' overall effect on activity, gait and other cognitive functions does not seem superior to conventional therapy.
... Adaptive assistance, for instance, cooperatively engages the patient and introduces gait variations that can lead to retraining the neural network in the spinal cord [59]. Cognitive challenges also can lead to actively engage patients to simultaneously improve motor and cognitive deficits [60]. Another approach to challenge patients while preventing cognitive stress and frustration is to adaptively change the difficulty of the training according to patients capabilities [61], as it has been shown that matching the complexity of tasks to the skill level of the patients leads to improvement of learning efficacy [62]. ...
Powered lower limb exoskeletons (PLLE) have attracted much interest due to their potential applications. They provide assistance for persons with disabilities to accomplish activities of daily living (ADL), and more importantly assist them in achieving their rehabilitation goals. However, still there are unclear evidences on the quality and benefits that PLLEs can deliver to patients. This is due to limited usability and performance of current PLLEs, insufficient clinical use of PLLEs for different patients with high diversity in their disability type and impairment, and also the large gap between the technological state of the art and clinical expectations. In this study, we review and analyse various factors that can improve the effectiveness of PLLEs at yielding better assistance and rehabilitation training for patients with motor impairments. First, we define a set of criteria that characterize the majority of expectations for the rehabilitation and assistance domains and we use them for evaluating PLLEs depending on the context. Then, we include the effects of control strategies and combined approaches which include auxiliary devices such as Functional electrical stimulation and smart crutches applied to PLLEs with regard to the criteria we defined.
... The purpose of Ref. [62] was to assess the therapeutic effects of a serious game and a scoring system created for lower limb motor rehabilitation of hemiparetic stroke patients, which were inspired by the Pong videogame, in which the aim is to manage a tennis racquet using muscular strength rather than hand strength. ROBiGAME [63] was a serious game designed to treat both physical and cognitive deficiencies following a stroke. Souza et al. [64] developed a camera tracking Handcopter Game that may be used as part of the patient's treatment to aid in the recovery of motor function in patients who had recently experienced a stroke. ...
... The exercise data can be recorded and sent to a computer via Bluetooth to track rehabilitation progress. RoBiGAME, a robot-assisted serious game with a sandwich shop scenario for post-stroke cognitive rehabilitation, was developed [10]. The system provides different types of feedback: sound effects, lighting, and client mood to stimulate and encourage the player. ...
... The purpose of Ref. [62] was to assess the therapeutic effects of a serious game and a scoring system created for lower limb motor rehabilitation of hemiparetic stroke patients, which were inspired by the Pong videogame, in which the aim is to manage a tennis racquet using muscular strength rather than hand strength. ROBiGAME [63] was a serious game designed to treat both physical and cognitive deficiencies following a stroke. Souza et al. [64] developed a camera tracking Handcopter Game that may be used as part of the patient's treatment to aid in the recovery of motor function in patients who had recently experienced a stroke. ...
This paper describes a serious game based on a knowledge transfer model using deep reinforcement learning, with an aim to improve the caretakers’ knowledge and abilities in post-stroke care. The iTrain game was designed to improve caregiver knowledge and abilities by providing non-traditional training to formal and informal caregivers who deal with stroke survivors. The methodologies utilized professional medical experiences and real-life evidence data gathered during the duration of the iTrain project to create the scenarios for the game’s deep reinforcement caregiver behavior improvement model, as well as the design of game mechanics, game images and game characters, and gameplay implementation. Furthermore, the results of the game’s direct impact on caregivers (n = 25) and stroke survivors (n = 21) in Lithuania using the Geriatric Depression Scale (GDS) and user experience questionnaire (UEQ) are presented. Both surveys had favorable outcomes, showing the effectiveness of the approach. The GDS scale (score 10) revealed a low number of 28% of individuals depressed, and the UEQ received a very favorable grade of +0.8.
... Certain serious game-based RATs offer the opportunity to rehabilitate specific cognitive functions while providing real-time feedback during motor rehabilitation. 96 ...
Background:
Robot-assisted therapy (RAT) could address an unmet need to relieve the strain on healthcare providers and intensify treatment in the context of an increasing stroke incidence. A comprehensive meta-analysis could provide firmer data about the topic by considering methodology limitations discovered in previous reviews and providing more rigorous evidence.
Objective:
This meta-analysis study identifies RAT's efficacy for patients with stroke.
Methods:
A systematic search of the 7 databases from January 10 to February 1, 2022, located relevant publications. We used the updated Cochrane risk-of-bias checklist for 52 trials to assess the methodologic quality of the included studies. The efficacy of RAT for patients with stroke was estimated using a pooled random-effects model in the Stata 16 software application.
Results:
The final analysis included 2774 patients with stroke from 52 trials. In those patients, RAT was proven to improve quality of movement (mean difference, 0.15; 95% confidence interval, 0.03-0.28) and to reduce balance disturbances (mean difference, -1.28; 95% confidence interval, -2.48 to -0.09) and pain (standardized mean difference, -0.34; 95% confidence interval, -0.58 to -0.09).
Conclusions:
Robot-assisted therapy seems to improve the quality of mobility and reduce balance disturbances and pain for patients with stroke. These findings will help develop advanced rehabilitation robots and could improve health outcomes by facilitating health services for healthcare providers and patients with stroke.
... Due to its promising aspect, the adaptation of games has been investigated in several studies, in which researchers have explored the adaptation of games according to the users' needs, characteristics or experience. In this sense, [15] and [27] conducted studies to adapt serious games for motor rehabilitation according to the patient's performance. Beyond the scope of health applications, Papadimitriou et al. [25] proposed an adaptive educational game that changes the difficulty level of quizzes considering the learner's progress. ...
Serious games have been applied in many contexts, aiming to turn learning and training activities more attractive for users. The motor rehabilitation process is a scenario in which serious games present benefits such as keeping the user’s motivation. Nevertheless, the development of these games is a complex task, especially when user’s motivation is a key goal. Some strategies have been investigated to automatically adapt these games to keep one’s engagement. However, fast implementation with little effort is an open issue. To support a game with automatic adaptation considering the emotional state of the user, we propose an Affective Computing framework, called EasyAffecta. EasyAffecta provides benefits for physiotherapists, developers, and patients alike. The impact of our proposal was analyzed by conducting two experimental evaluations involving different actors. The first one was carried with patients of motor rehabilitation process. Additionally, we conducted an experimental evaluation with developers. The results showed that EasyAffecta was considered useful by developers and efficient to maintain the patient’s engagement.
... Therefore, multi-sensor fusion could be a promising method to improve EMG-based recognition accuracy for stroke patients. In addition, to optimize the engagement of patients (Witmer and Singer, 1998), serious games have been designed and utilized in rehabilitation systems (Mohammadzadeh et al., 2015), (Heins et al., 2017), (Nissler et al., 2019). The effectiveness of serious games has been shown to show better results than conventional approaches for upper limb motor function rehabilitation (Tăut et al., 2017). ...
Stroke often leads to hand motor dysfunction, and effective rehabilitation requires keeping patients engaged and motivated. Among the existing automated rehabilitation approaches, data glove-based systems are not easy to wear for patients due to spasticity, and single sensor-based approaches generally provided prohibitively limited information. We thus propose a wearable multimodal serious games approach for hand movement training after stroke. A force myography (FMG), electromyography (EMG), and inertial measurement unit (IMU)-based multi-sensor fusion model was proposed for hand movement classification, which was worn on the user’s affected arm. Two movement recognition-based serious games were developed for hand movement and cognition training. Ten stroke patients with mild to moderate motor impairments (Brunnstrom Stage for Hand II-VI) performed experiments while playing interactive serious games requiring 12 activities-of-daily-living (ADLs) hand movements taken from the Fugl Meyer Assessment. Feasibility was evaluated by movement classification accuracy and qualitative patient questionnaires. The offline classification accuracy using combined FMG-EMG-IMU was 81.0% for the 12 movements, which was significantly higher than any single sensing modality; only EMG, only FMG, and only IMU were 69.6, 63.2, and 47.8%, respectively. Patients reported that they were more enthusiastic about hand movement training while playing the serious games as compared to conventional methods and strongly agreed that they subjectively felt that the proposed training could be beneficial for improving upper limb motor function. These results showed that multimodal-sensor fusion improved hand gesture classification accuracy for stroke patients and demonstrated the potential of this proposed approach to be used as upper limb movement training after stroke.
... Seventy-five percent of stroke survivors suffer from upper limb dysfunction, which limits their performance in daily life [2]. Effective rehabilitation should be longterm, repetitive, and intensive for stroke patients' neurological restoration [3], [4], [5]. Normally, patients in acute and subacute stages stay in the hospital, receiving conventional rehabilitation such as occupational therapies (OT) with the assistance of therapists, which is labor-intensive and consumes medical resources. ...
Most stroke survivors have difficulties completing activities of daily living (ADLs) independently. However, few rehabilitation systems have focused on ADLs-related training for gross and fine motor function together. We propose an ADLs-based serious game rehabilitation system for the training of motor function and coordination of both arm and hand movement where the user performs corresponding ADLs movements to interact with the target in the serious game. A multi-sensor fusion model based on electromyographic (EMG), force myographic (FMG), and inertial sensing was developed to estimate users' natural upper limb movement. Eight healthy subjects and three stroke patients were recruited in an experiment to validate the system's effectiveness. The performance of different sensor and classifier configurations on hand gesture classification against the arm position variations were analyzed, and qualitative patient questionnaires were conducted. Results showed that elbow extension/flexion has a more significant negative influence on EMG-based, FMG-based, and EMG+FMG-based hand gesture recognition than shoulder abduction/adduction does. In addition, there was no significant difference in the negative influence of shoulder abduction/adduction and shoulder flexion/extension on hand gesture recognition. However, there was a significant interaction between sensor configurations and algorithm configurations in both offline and real-time recognition accuracy. The EMG+FMG-combined multi-position classifier model had the best performance against arm position change. In addition, all the stroke patients reported their ADLs-related ability could be restored by using the system. These results demonstrate that the multi-sensor fusion model could estimate hand gestures and gross movement accurately, and the proposed training system has the potential to improve patients' ability to perform ADLs.
... Similar to SGER for cognitive/motor rehabilitation, SGER for integrated rehabilitation also widely applies advanced technologies such as VR, AR, and difficulty adaptation. RO-BiGAME [55] was a SGER for integrated rehabilitation used on the robot end-effector REAplan. REAplan could adjust the control difficulty of the handle in real-time according to the patient's performance in the game to ensure the safety and effectiveness of the patient's upper limb exercise rehabilitation process. ...
Disability is an important factor affecting todays society. At the same time, more and more sub-healthy people are sick due to reduced body functions and cognitive functions. Exercise rehabilitation is a kind of physical therapy, which can recover the motor ability, cognitive ability, and mental state of them through exercise. But the traditional exercise rehabilitation has some drawbacks so that people who need exercise rehabilitation cannot stick to it. Therefore, many researchers improved the drawbacks of traditional exercise rehabilitation by serious games for exercise rehabilitation. Although there were abundant achievements in the games, its relevant technologies and representative games are not be summarized systematically. To fill this gap, we introduced the significance of the convergence of exercise rehabilitation and serious games. Then, our paper sorted out the development of the games based on interaction mode between games and players. Besides, we analyzed the characteristics of different user groups and the specific functions of the games corresponding to them, and gave our classification based on this. Based on the classification, we reviewed related studies of the games in the past decade years and gave some suggestions on game design and development. Finally, we proposed serval research directions worth studying about the games technology development, functional design and social popularization.
... Players can move their feet to cross obstacles in the game for rehabilitation. Heins et al. [47] created a ROBiGAME game for sports and cognitive rehabilitation. This game can evaluate patients' postoperative performance and improve the rehabilitation effect. ...
Medical operations (MOs) are essential in healthcare,and they are also a big concept that includes various operations during the perioperative period.Traditional operation exposes its limitations during the perioperative period,reflected in medical training,surgical preparation,and postoperative rehabilitation.Serious Games for Medical Operation (SGMO) offer new ways and complementary solutions to support MOs.As a review,this paper analyzes the development of SGMO and considers various aspects of the SGMO,such as interface,functions,and technologies.By combining MO and serious games characteristics,the paper classifies SGMO and analyzes their features and functions for different groups of users and at various stages of the perioperative period (before,during,and after an MO).Interactive technologies used in SGMO are presented from a visual,haptic,and auditory perspective.This paper reviews the development of SGMO,summarizes its functions and technologies.Besides,it presents representative products and suggests future research directions.
... Therefore, multi-sensor fusion could be a promising method to improve sEMGbased recognition accuracy for stroke patients. In addition, to optimize the engagement of patients [37], a large amount of games have been designed and utilized in rehabilitation systems [38], [39], [40]. The effectiveness of serious games has proven to be better than conventional rehabilitation in upper limb motor function rehabilitation [41]. ...
Objective: Stroke often leads to both motor control and cognitive dysfunction, and effective rehabilitation requires keeping patients engaged and motivated. We introduce a wearable multimodal system based on force myography, electromyography, and inertial sensing with two associated serious games for stroke rehabilitation of twelve hand movements related to activities of daily living and the Fugl Meyer Assessment.
Methods: In the ‘Find the Sheep’ serious game, patients performed corresponding hand movements to select the correct sheep card, and in the ‘Best Salesman’ serious game, patients performed corresponding hand movements to grab specific food and drink items in a store. A multi-sensor fusion model was developed for movement classification via linear discriminant analysis. Ten stroke patients with mild to moderate motor impairments (Brunnstrom Stage for Hand II-VI) performed validation testing, and effectiveness was evaluated by movement classification accuracy and qualitative patient questionnaires.
Results: Classification accuracy for twelve movements using combined force myography, electromyography, and inertial sensing was 81.0%, and accuracies for using electromyography, force myography, or inertial sensing alone were 69.6%, 63.2%, and 47.8%, respectively. All patients reported that they were more enthusiastic about rehabilitation while playing serious games than conventional rehabilitation, and a majority reported the wearable multimodal-based system was easier to wear than a sensorized data glove.
Significance: Results showed that multi-sensor fusion could improve hand gesture classification accuracy for stroke patients and demonstrated that the proposed wearable multimodal-serious game system could potentially facilitate upper extremity rehabilitation and cognitive training after stroke.
... Recently, game technology is becoming a popular way to motivate, engage and appeal to users in cognitive tasks, since traditional cognitive tasks are usually effortful, frustrating, repetitive, and disengaging. Serious games and brain training games are a growing research field for cognitive training (Heins et al., 2017). Integration between gaming and robotic technologies has attracted increasing amount of interest in research and application, to further enhance users' engagement in cognitive training. ...
A large and increasing number of people around the world experience cognitive disability. Rehabilitation robotics has provided promising training and assistance approaches to mitigate cognitive deficits. In this article, we carried out a systematic review on recent developments in robot-assisted cognitive training. We included 99 articles in this work and described their applications, enabling technologies, experiments, and products. We also conducted a meta analysis on the articles that evaluated robot-assisted cognitive training protocol with primary end users (i.e., people with cognitive disability). We identified major limitations in current robotics rehabilitation for cognitive training, including the small sample size, non-standard measurement of training and uncontrollable factors. There are still multifaceted challenges in this field, including ethical issues, user-centered (or stakeholder-centered) design, the reliability, trust, and cost-effectiveness, personalization of the robot-assisted cognitive training system. Future research shall also take into consideration human-robot collaboration and social cognition to facilitate a natural human-robot interaction.
... Seventy-five percent of stroke survivors suffer from upper limb dysfunction, which limits their performance in daily life [2]. Effective rehabilitation should be longterm, repetitive, and intensive for stroke patients' neurological restoration [3], [4], [5]. Normally, patients in acute and subacute stages stay in the hospital, receiving conventional rehabilitation such as occupational therapies (OT) with the assistance of therapists, which is labor-intensive and consumes medical resources. ...
Background
The foot progression angle is an important measure used to help patients reduce their knee adduction moment. Current measurement systems are either lab-bounded or do not function in all environments (e.g., magnetically distorted). This work proposes a novel approach to estimate foot progression angle using a single foot-worn inertial sensor (accelerometer and gyroscope).
Methods
The approach uses a dynamic step frame that is recalculated for the stance phase of each step to calculate the foot trajectory relative to that frame, to minimize effects of drift and to eliminate the need for a magnetometer. The foot progression angle (FPA) is then calculated as the angle between walking direction and the dynamic step frame. This approach was validated by gait measurements with five subjects walking with three gait types (normal, toe-in and toe-out).
Results
The FPA was estimated with a maximum mean error of ~ 2.6° over all gait conditions. Additionally, the proposed inertial approach can significantly differentiate between the three different gait types.
Conclusion
The proposed approach can effectively estimate differences in FPA without requiring a heading reference (magnetometer). This work enables feedback applications on FPA for patients with gait disorders that function in any environment, i.e. outside of a gait lab or in magnetically distorted environments.
... Most stroke survivors require motor rehabilitation because of upper limb impairments [4]. Effective therapies need to be intensive, repetitive, purposeful, and associated movement feedback [5], [6] to increase muscle strength and promote neurological restoration of functional abilities [7]. About 60% of stroke patients also experience cognitive decline after stroke [8], typically related to degradation in memory, executive function and attention [9]. ...
... Then, standard deviation was subtracted resulting in 66.48% and rounded to 70%. As a result, 33 articles were included in this review for further analysis, whereas the remaining 8 articles [83][84][85][86][87][88][89][90] were excluded because their percentages were below 70% (i.e., between 37% and 66%). The QualSyst score was low in some studies because the assessing points 2, 10, 12, and 13 of the QualSyst standard were partially or not covered. ...
This systematic review aims to analyze the state-of-the-art regarding interaction modalities used on serious games for upper limb rehabilitation. A systematic search was performed in IEEE Xplore and Web of Science databases. PRISMA and QualSyst protocols were used to filter and assess the articles. Articles must meet the following inclusion criteria: they must be written in English; be at least four pages in length; use or develop serious games; focus on upper limb rehabilitation; and be published between 2007 and 2017. Of 121 articles initially retrieved, 33 articles met the inclusion criteria. Three interaction modalities were found: vision systems (42.4%), complementary vision systems (30.3%), and no-vision systems (27.2%). Vision systems and no-vision systems obtained a similar mean QualSyst (86%) followed by complementary vision systems (85.7%). Almost half of the studies used vision systems as the interaction modality (42.4%) and used the Kinect sensor to collect the body movements (48.48%). The shoulder was the most treated body part in the studies (19%). A key limitation of vision systems and complementary vision systems is that their device performances might be affected by lighting conditions. A main limitation of the no-vision systems is that the range-of-motion in angles of the body movement might not be measured accurately. Due to a limited number of studies, fruitful areas for further research could be the following: serious games focused on finger rehabilitation and trauma injuries, game difficulty adaptation based on user's muscle strength and posture, and multisensor data fusion on interaction modalities.
... Then, standard deviation was subtracted resulting in 66.48% and rounded to 70%. As a result, 33 articles were included in this review for further analysis, whereas the remaining 8 articles [83][84][85][86][87][88][89][90] were excluded because their percentages were below 70% (i.e., between 37% and 66%). The QualSyst score was low in some studies because the assessing points 2, 10, 12, and 13 of the QualSyst standard were partially or not covered. ...
This systematic review aims to analyze the state-of-the-art regarding interaction modalities used on serious games for upper limb rehabilitation. A systematic search was performed in IEEE Xplore and Web of Science databases. PRISMA and QualSyst protocols were used to filter and assess the articles. Articles must meet the following inclusion criteria: they must be written in English; be at least four pages in length; use or develop serious games; focus on upper limb rehabilitation; and be published between 2007 and 2017. Of 121 articles initially retrieved, 33 articles met the inclusion criteria. Three interaction modalities were found: vision systems (42.4%), complementary vision systems (30.3%), and no-vision systems (27.2%). Vision systems and no-vision systems obtained a similar mean QualSyst (86%) followed by complementary vision systems (85.7%). Almost half of the studies used vision systems as the interaction modality (42.4%) and used the Kinect sensor to collect the body movements (48.48%). The shoulder was the most treated body part in the studies (19%). A key limitation of vision systems and complementary vision systems is that their device performances might be affected by lighting conditions. A main limitation of the no-vision systems is that the range-of-motion in angles of the body movement might not be measured accurately. Due to a limited number of studies, fruitful areas for further research could be the following: serious games focused on finger rehabilitation and trauma injuries, game difficulty adaptation based on user’s muscle strength and posture, and multisensor data fusion on interaction modalities.
... Since then, a variety of games employing robots, tangible surfaces, and VR systems have been proposed for stroke rehabilitation. Specific applications include a robotic-assisted game for motor and cognitive post-stroke rehabilitation (Heins et al. 2017), a multi-user VR game for upper extremity rehabilitation (Tsoupikova et al. 2016), and a tangible gaming board for the training of upper limb gross and fine motor skills (Wang et al. 2017). ...
Modern immersive virtual reality experiences have the unique potential to motivate patients undergoing physical therapy for performing intensive repetitive task-based treatment and can be utilized to collect real-time user data to track adherence and compliance rates. This article reports the design and evaluation of an immersive virtual reality game using the HTC Vive for upper limb rehabilitation, titled “Project Star Catcher” (PSC), aimed at users with hemiparesis. The game mechanics were adapted from modified Constraint Induced Therapy (mCIT), an established therapy method where users are asked to use the weaker arm by physically binding the stronger arm. Our adaptation changes the physical to psychological binding by providing various types of immersive stimulation to influence the use of the weaker arm. PSC was evaluated by users with combined developmental and physical impairments as well as stroke survivors. The results suggest that we were successful in providing a motivating experience for performing mCIT as well as a cost-effective solution for real-time data capture during therapy. We conclude the article with a set of considerations for immersive virtual reality therapy game design.
... meramente jugar, tal que puede ser educativo, de entrenamiento, de rehabilitación, entre otros fines, y en particular, cuya dinámica surja en función de lo que va aconteciendo en el contexto [1]. Los juegos serios emergentes parten de dos teorías, la de juegos serios que establece que es un juego que tiene un propósito específico, el cual puede estar relacionado con el aprendizaje, con la comprensión de un tema complejo [2,[19][20][21]; y la de sistemas emergentes, que son sistemas cuyos comportamientos surgen a partir de las interacciones espontáneas de los elementos relativamente simples que los componen, sin leyes explícitas [3,4]. En ese sentido, estos tipos de juegos requieren de un MJSE específico a sus características. ...
Un motor de juegos serios emergentes (MJSE) debe hacer explícito la posibilidad de emergencia en un juego serio, a partir delmanejo coordinado de tramas de juegos, adaptadas al contexto educativo especifico donde se esté desarrollando el juego. En particular, en anteriores trabajos se ha propuesto una arquitectura jerárquica para el MJSE, constitutiva de submotores. El objetivo principal de este trabajo es especificar los submotores encargados del proceso de emergencia del juego serio, los cuales se basan en el algoritmo de optimización basado en colonias de hormigas (ACO). Dichos submotores realizan la gestión del conjunto de tramas de juego según el contexto-dominio educativo de interés, de tal manera de fusionarlas en una única trama, para hacer de esta forma emerger la dinámica del juego serio. Adicionalmente, en este trabajo se analiza el comportamiento de dichos submotores en un caso de estudio, mostrando resultados muy alentadores como MJSE.
... The results are complementary to those obtained from clinical scales. Kinematic indices can also be used to tailor the therapeutic exercises provided by the robot to the specific needs of the patient (16). As for kinematics, spasticity can also be included in robotic assessment protocols, as it limits the speed and direction of active movements of the upper limb. ...
Objective:
To assess the capacity of the robotic device REAplan to measure overall upper limb peak resistance force, as a reflection of upper limb spasticity.
Methods:
Twelve patients with chronic stroke presenting upper limb spasticity were recruited to the study. Patients underwent musculocutaneous motor nerve block to reduce the spasticity of elbow flexor muscles. Each patient was assessed before and after the motor nerve block. Overall the REAplan measured upper limb resistance force. The robot passively mobilized the patient's upper limb at various velocities (10, 20, 30, 40 and 50 cm/s) in a back-and-forth trajectory (30 cm). The peak resistance force was analysed for each forward movement. Ten movements were performed and averaged at each velocity condition.
Results:
The overall upper limb resistance force increased proportionally to the mobilization velocity (p < 0.001). Resistance force decreased after the motor nerve block at 40 and 50 cm/s (p < 0.05). Overall upper limb resistance force results showed excellent correlation with the Modified Ashworth Scale for elbow flexor muscles, for each velocity condition equal or higher than 30 cm/s (ρ >0.6).
Conclusion:
This study proposes a new, valid, reliable and sensitive protocol to quantify upper limb resistance force using the REAplan, as a reflection of upper limb spasticity.
Eye contact is one of the main human skills, and a prerequisite of verbal language. However, children with Autism Spectrum Disorder (ASD) often have an important deficit in this skill, compromising their entire cognitive and social development. This work shows the development of two Serious Games (SGs), based on the concept of Child-Robot Interaction (CRI), for the exercise and improvement of eye contact and visual attention, as well as concepts such as imitation and emotion recognition. For face detection and eye movement monitoring, an open source development framework of machine learning named MediaPipe was used. Tests with children with ASD will be conducted, and it is expected these SGs have a positive impact regarding the improvement of both eye contact and visual attention for these children.
Powered Lower Limb Exoskeletons (PLLE) have attracted much interest due to their potential applications. They provide assistance for persons with disabilities to accomplish activities of daily living (ADL), and more importantly, assist them in achieving their rehabilitation goals. However, there is still uncertainty regarding the quality and benefits that PLLEs can offer to patients. This is due to limited usability and performance of current PLLEs, insufficient clinical use of PLLEs for different patients with high diversity in their disability type and impairment, and also the large gap between the technological state of the art and clinical expectations. In this study, we review and analyse various factors that can improve the effectiveness of PLLEs at yielding better assistance and rehabilitation training for patients with motor impairments. First, we define a set of criteria that characterize the majority of expectations for the rehabilitation and assistance domains and we use them for evaluating PLLEs depending on the context. Then, we include the effects of control strategies and combined approaches which include auxiliary devices such as functional electrical stimulation and smart crutches applied to PLLEs with regard to the criteria we defined.
Subjective feelings feedbacks are commonly employed by a patient during forearm rehabilitation therapy without real-time data, leading to suboptimal recovery results in some patients. Technological innovations in the field of assisted rehabilitation have enabled the evolution of real-time monitoring systems. In this paper, interactive assistant development is presented as the interface to define the relationship between the kinematics patterns and the electromyographic signals during the forearm rehabilitation routine. Leap Motion (LM) and Shimmer3 EMG sensors read the routine behavior by following the movements that appear on the software. Real-time targets are programmed to lead the necessary forearm movements that the therapist sets to determine the recovery progress. The integration of software and hardware shows a dataset basis on interaction variables such as arm velocity, arm position, performance rate, and electrical muscle pulse. The results obtained from tests show that the system works effectively within a range of movement of 9 to 88 degrees in rotation about the axes, and velocities under 190 mm/s show stable movement representation on software. Finally, the outcomes ranges show an alternative tool to evaluate patients with a forearm injury.
It is noticeable that more and more medical professionals have been searching for strategies to keep people engaged both in the recovery processes (cognitive or physical) and in the teaching part. It is possible to observe that the insertion of Serious Games has been offering this innovative possibility, which allows the development of new possibilities for several areas of knowledge. This study aims to carry out a review on the use of Serious Games in Medicine, exploring how the method has been used. The methodology used was a systematic review. Articles published from 2015 to 2020 in indexed in three databases such as IEEE, Scopus, Scielo, among others, were searched. If used correctly, the Serious Games can help in the rehabilitation process of patients affected by some sequelae caused by stroke (CVA - Cerebral Vascular Accident), and also in the rehabilitation process of people with degenerative problems. It was also possible to observe that SG can be used as motivating and engaging tools for medical students.
This paper presents a system developed by the authors that makes use of a new trend in rehabilitation, serious gaming. Short introduction and state of the art is presented in the first part of the paper, after which the main design steps are given and explained. Finally, the testing of the prototype as well as the lesson learnt from building it are discussed in the last part of the paper. The aim of the research was to create an equipment that might be further developed into a fully-fledged rehabilitation device that uses the serious gaming paradigm.
Stroke is affecting different age groups worldwide with tremendous consequences. Most stroke survivors suffer from motor impairment, where rehabilitation helps to regain lost abilities. Rehabilitation is a long process that focuses on repeating exercises, which are monotonous and time-consuming. As a consequence, patients loose interest and motivation. Serious games offer the possibility to deliver rehabilitation exercises in combination with entertaining and motivating aspects. A variety of serious games using additional hardware is available to support stroke patients. The authors propose a new and innovative serious game, which rely only on integrated sensors of a smartphone. Development was based on a user-centred design approach divided into 2 phases. In phase 1 requirements were identified in cooperation with a therapist and 13 stroke patients. The developed serious game included different levels of difficulty for movement, gesture and touch exercises. Additional feedback and requirements from therapists and medical doctors were included in phase 2, which resulted in an advanced solution with additional levels. Gathered feedback showed a positive attitude towards the proposed solution.
Background:
The ROBiGAME project aims to implement serious games on robots to rehabilitate upper limb (UL) motor function in children with cerebral palsy (CP). Serious game characteristics (target position, level of assistance/resistance, level of force) are typically adapted based on the child's assessment before and continuously during the game (measuring UL working area, kinematics and muscle strength).
Objective:
This study developed an UL robotic motor assessment protocol to configure the serious game.
Methods:
Forty-nine healthy children and 20 CP children participated in the study. The clinical assessment consisted of the child's UL length and isometric force. The robot assessment consisted of the child's UL working area (WA), the UL isometric and isokinetic force in three directions and the UL kinematics during a pointing task toward targets placed at different distances.
Results:
Results showed that WA and UL isometric force were moderately to highly correlated with clinical measures. Ratios between the UL isokinetic force generated on three directions were established. The velocity and straightness indexes of all children increased when they had to reach to targets placed more distant.
Conclusions:
This protocol can be integrated into different serious games in order to continuously configure the game characteristics to a child's performance.
Trial registration:
The study was registered at ClinicalTrials.gov (NCT02543424), 12 August 2015.
Accessibility is a feature that often is not considered in the design of products or services and video games market is not the exception. Serious games is a category of video games that allows to educate in different areas through fun. They have become an important support tool in the learning process. However, most serious games do not focus on vulnerable groups such as people with motor impairments. On the other hand, the number of mobile serious games has increased with the use of mobile devices. Despite this, accessibility for people with motor impairments has not yet been considered a necessary feature in the development of this type of video games. Some video game developer groups recommend general accessibility guidelines for the design of such applications. However, it has become necessary to formalize, consolidate and analyze these initiatives in order to define a model for evaluating the accessibility of video games for people with motor impairments. This paper presents a compilation and analysis of accessibility guidelines for the development of video games for people with motor impairments. It also proposes a categorization of existing guidelines that allow to evaluate a video game accessibility level. As a case study, these accessibility guidelines are used to assess some mobile serious games and identify their accessibility level for people with motor impairments. We propose an assessment tool for those who wish to develop accessible serious games for people with motor impairments on mobile devices.
This is the protocol for a review and there is no abstract. The objectives are as follows: To carry out a Cochrane Overview, synthesising systematic reviews of interventions to improve upper limb function after stroke.
Background
Virtual Reality (VR) based methods for stroke rehabilitation have mainly focused on motor rehabilitation, but there is increasing interest in integrating motor and cognitive training to increase similarity to real-world settings. Unfortunately, more research is needed for 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 Socioemotional Selectivity Theory, as people age, the emotional salience arises for positive and neutral, but not for negative stimuli.
Methods
For this study we developed a cognitive-motor VR task involving attention and short-term memory, and we investigated the impact of using emotional images of varying valence. The task consisted of finding a target image, shown for only two seconds, among fourteen neutral distractors, and selecting it through arm movements. After performing the VR task, a recall task took place and the patients had to identify the target images among a valence-matched number of distractors. Ten stroke patients participated in a within-subjects experiment with three conditions based on the valence of the images: positive, negative and neutral. Eye movements were recorded during VR task performance with an eye tracking system.
Results
Our results show decreased attention for negative stimuli in the VR task performance when compared to neutral stimuli. The recall task shows significantly more wrongly identified images (false memories) for negative stimuli than for neutral. Regression and correlation analyses with the Montreal Cognitive Assessment and the Geriatric Depression Scale revealed differential effects of cognitive function and depressive symptomatology in the encoding and recall of positive, negative and neutral images. Further, eye movement data shows reduced search patterns for wrongly selected stimuli containing emotional content.
Conclusions
The results of this study suggest that it is feasible to use emotional content in a VR based cognitive-motor task for attention and memory training after stroke. Stroke survivors showed less attention towards negative information, exhibiting reduced visual search patterns and more false memories. We have also shown that the use of emotional stimuli in a VR task can provide additional information regarding patient’s mood and cognitive status.
Background
Electromechanical and robot-assisted armtraining devices are used in rehabilitation, and may help to improve arm function after stroke.
Objectives
To assess the effectiveness of electromechanical and robot-assisted arm training for improving activities of daily living, arm function,
and arm muscle strength in people after stroke. We also assessed the acceptability and safety of the therapy.
Search methods
We searched the Cochrane Stroke Group’s Trials Register (last searched February 2015), the Cochrane Central Register of Controlled
Trials (CENTRAL) (the Cochrane Library 2015, Issue 3), MEDLINE (1950 to March 2015), EMBASE (1980 to March 2015),
CINAHL (1982 to March 2015), AMED (1985 to March 2015), SPORTDiscus (1949 to March 2015), PEDro (searched April
2015), Compendex (1972 toMarch 2015), and Inspec (1969 toMarch 2015). We also handsearched relevant conference proceedings,
searched trials and research registers, checked reference lists, and contacted trialists, experts, and researchers in our field, as well as
manufacturers of commercial devices.
Selection criteria
Randomised controlled trials comparing electromechanical and robot-assisted arm training for recovery of arm function with other
rehabilitation or placebo interventions, or no treatment, for people after stroke.
Data collection and analysis
Two review authors independently selected trials for inclusion, assessed trial quality and risk of bias, and extracted data. We contacted
trialists for additional information. We analysed the results as standardised mean differences (SMDs) for continuous variables and risk
differences (RDs) for dichotomous variables.
Main results
We included 34 trials (involving 1160 participants) in this update of our review. Electromechanical and robot-assisted arm training
improved activities of daily living scores (SMD 0.37, 95% confidence interval (CI) 0.11 to 0.64, P = 0.005, I² = 62%), arm function
(SMD 0.35, 95% CI 0.18 to 0.51, P < 0.0001, I² = 36%), and arm muscle strength (SMD 0.36, 95% CI 0.01 to 0.70, P = 0.04, I² =
72%), but the quality of the evidence was low to very low. Electromechanical and robot-assisted arm training did not increase the risk
of participant drop-out (RD 0.00, 95% CI -0.02 to 0.03, P = 0.84, I² = 0%) with moderate-quality evidence, and adverse events were
rare.
Authors’ conclusions
People who receive electromechanical and robot-assisted arm and hand training after stroke might improve their activities of daily
living, arm and hand function, and arm and hand muscle strength. However, the results must be interpreted with caution because
the quality of the evidence was low to very low, and there were variations between the trials in the intensity, duration, and amount of
training; type of treatment; and participant characteristics.
The aim of this article is to describe a game engine that has all the characteristics needed to support rehabilitation at home. The low-cost tracking devices recently introduced in the entertainment market allow measuring reliably at home, in real time, players' motion with a hands-free approach. Such systems have also become a source of inspiration for researchers working in rehabilitation. Computer games appear suited to guide rehabilitation because of their ability to engage the users. However, commercial videogames and game engines lack the peculiar functionalities required in rehabilitation: Games should be adapted to each patient's functional status, and monitoring the patient's motion is mandatory to avoid maladaptation. Feedback on performance and progression of the exercises should be provided. Lastly, several tracking devices should be considered, according to the patient's pathology and rehabilitation aims.
We have analyzed the needs of the clinicians and of the patients associated in performing rehabilitation at home, identifying the characteristics that the game engine should have.
The result of this analysis has led us to develop the Intelligent Game Engine for Rehabilitation (IGER) system, which combines the principles upon which commercial games are designed with the needs of rehabilitation. IGER is heavily based on computational intelligence: Adaptation of the difficulty level of the exercise is carried out through a Bayesian framework from the observation of the patient's success rate. Monitoring is implemented in fuzzy systems and based on rules defined for the exercises by clinicians. Several devices can be attached to IGER through an input abstraction layer, like the Nintendo(®) (Kyoto, Japan) Wii™ Balance Board™, the Microsoft(®) (Redmond, WA) Kinect, the Falcon from Novint Technologies (Albuquerque, NM), or the Tyromotion (Graz, Austria) Timo(®) plate balance board. IGER is complemented with videogames embedded in a specific taxonomy developed to support rehabilitation progression through time.
A few games aimed at postural rehabilitation have been designed and developed to test the functionalities of the IGER system. The preliminary results of tests on normal elderly people and patients with the supervision of clinicians have shown that the IGER system indeed does feature the characteristics required to support rehabilitation at home and that it is ready for clinical pilot testing at patients' homes.
Objective:
To validate a protocol assessing upper limb kinematics using a planar robot among stroke patients.
Design:
Prospective cohort study.
Subjects:
Age-matched healthy subjects (n = 25) and stroke patients (n = 25).
Methods:
Various kinematic indices (n = 44) were obtained from 4 tasks performed by subjects with REAplan, a planar end-effector robotic device. The metrological properties of this protocol were studied.
Results:
In stroke patients, 43 kinematic indices showed moderate to excellent reliability (intraclass correlation coefficients (ICC) range 0.40-0.95; and minimal detectable changes range 9.9-121.1%). In healthy subjects, 25 kinematic indices showed moderate to excellent reliability (ICC range 0.40-0.91) and 3 indices showed a laterality effect (p < 0.05). Many of these indices (27 of 44) were altered in stroke patients in comparison with healthy subjects (p < 0.05). The Box and Block test (manual dexterity) and Upper Limb Sub-score of the Fugl-Meyer Assessment (motor control) showed moderate to good correlations with, respectively, 13 and 4 indices (r > 0.40). Finally, a principal component analysis allowed the elaboration of a short version of the protocol, reducing the number of indices to 5 (i.e. Amplitude, CVstraightness, Speed Metric, CVjerk metric and CVspeed metric).
Conclusion:
This study provides a standardized, valid, reliable and sensitive protocol to quantify upper limb impairments in stroke patients, using a planar robot.
Our goal is to apply robotics and automation technology to assist, enhance, quantify, and document neurorehabilitation. This paper reviews a clinical trial involving 20 stroke patients with a prototype robot-aided rehabilitation facility developed at the Massachusetts Institute of Technology, Cambridge, (MIT) and tested at Burke Rehabilitation Hospital, White Plains, NY. It also presents our approach to analyze kinematic data collected in the robot-aided assessment procedure. In particular, we present evidence 1) that robot-aided therapy does not have adverse effects, 2) that patients tolerate the procedure, and 3) that peripheral manipulation of the impaired limb may influence brain recovery. These results are based on standard clinical assessment procedures. We also present one approach using kinematic data in a robot-aided assessment procedure.
Purpose:
Given the incidence of stroke, the need has arisen to consider more self-managed rehabilitation approaches. A promising technology is Virtual Reality (VR). Thus far, however, it is not clear what the benefits of VR systems are when compared to conventional methods. Here we investigated the clinical impact of one such system, the Rehabilitation Gaming System (RGS), on the recovery time course of acute stroke. RGS combines concepts of action execution and observation with an automatic individualization of training. METHODS. Acute stroke patients (n = 8) used the RGS during 12 weeks in addition to conventional therapy. A control group (n = 8) performed a time matched alternative treatment, which consisted of intense occupational therapy or non-specific interactive games. RESULTS. At the end of the treatment, between-group comparisons showed that the RGS group displayed significantly improved performance in paretic arm speed that was matched by better performance in the arm subpart of the Fugl-Meyer Assessment Test and the Chedoke Arm and Hand Activity Inventory. In addition, the RGS group presented a significantly faster improvement over time for all the clinical scales during the treatment period. CONCLUSIONS. Our results suggest that rehabilitation with the RGS facilitates the functional recovery of the upper extremities and that this system is therefore a promising tool for stroke neurorehabilitation.
Our aim was to examine how brain imaging in the initial phase of a stroke could predict both acute/subacute as well as chronic spatial neglect. We present the first voxel-wise longitudinal lesion-behaviour mapping study, examining acute/subacute as well as chronic performance in the same individuals. Acute brain imaging (acquired on average 6.2 days post-injury) was used to evaluate neglect symptoms at the initial (mean 12.4 days post-stroke) and the chronic (mean 491 days) phase of the stroke. Chronic neglect was found in about one-third of the patients with acute neglect. Analysis suggests that lesion of the superior and middle temporal gyri predict both acute/subacute as well as chronic neglect. At the subcortical level, the basal ganglia as well as the inferior occipitofrontal fasciculus/extreme capsule appear to play a significant role for both acute/subacute as well as chronic neglect. Beyond, the uncinate fasciculus was critically related to the emergence of chronic spatial neglect. We infer that individuals who experience spatial neglect in the initial phase of the stroke yet do not have injury to these cortical and subcortical structures are likely to recover, and thus have a favourable prognosis.
Determining cognitive dysfunctioning (CDF) after stroke is an important issue because it influences choices for management in terms of return to previous activities. Because previous research in subacute stroke has shown important variations in CDF rates, we aimed to describe the frequency and neuropsychological profile of CDF in subacute stroke outside dementia. We used a large battery of tests to screen any potentially hidden CDF.
Patients with Mini-Mental State Examination scores >or=23 were prospectively and consecutively included 2 weeks after a first-ever ischemic brain infarct. Stroke features were based on MRI. Four domains were evaluated: instrumental and executive functions, episodic memory, and working memory (WM). Patients were scored using means and compared with education- and age-matched control subjects. Then we attributed Z-scores for each test and each domain. The most relevant cognitive tests characterizing CDF were determined using logistic regression.
Among 177 patients (mean age, 50.6 years), 91.5% failed in at least one cognitive domain. WM was the most impaired domain (87.6%) with executive functions (64.4%), episodic memory (64.4%), and instrumental functions (24.9%) being relatively preserved. CDF was associated with age, education, depression, neurological deficit, and leukoaraiosis in bivariate analysis. Using logistic regression, WM tests and age predicted CDF (Modified Paced Auditorial Serial Addition Test: OR=0.96 CI=0.93 to 0.98; Owen-spatial-WM: OR=1.07 CI=1.02 to 1.12; age: OR=0.96 CI=0.93 to 0.98).
CDF appears to be almost constant, although underestimated, in subacute stroke. WM could reflect some hidden dysfunctioning, which may interfere with rehabilitation and return to work. Clinical routine may include WM tests in young patients with mild stroke.
The goal of this study was to determine whether non immersive interactive virtual environments are an effective medium for training individuals who suffer from Unilateral Spatial Neglect (USN) as a result of a right hemisphere stroke, and to compare it to a standard computer visual scanning training.
Participants included 19 patients with right hemisphere stroke in two groups, 11 in an experimental group were given computer desktop-based Virtual Reality (VR) street crossing training and 8 in a control group who were given computer based visual scanning tasks, both for a total of twelve sessions, 9 hours total, over four weeks. Measures included: 1. Standard USN assessments, paper and pencil and ADL checklist; 2. Test on the VR street program; and 3. Actual street crossing videotaped. Testing was performed pre and post intervention.
The VR group achieved on the USN measures results that equaled those achieved by the control group treated with conventional visual scanning tasks. They improved more on the VR test and they did better on some measures of the real street crossing.
Despite several limitations in this study the present results support the effectiveness of the VR street program in the treatment of participants with USN, and further development of the program.
Serious games have increasingly become a good option with regards to professional training. However, the majority isn’t appropriate for people with cognitive disabilities, since there are several obstacles when developing for such a heterogeneous population.
This paper’s objective is to contribute for the development of serious games for people with cognitive disabilities by presenting a list of recommended design principles, collated from recent literature. A strong emphasis is placed on the adaptability of games since this is an important characteristic that ensures the game can be configured to fit to the needs of each player, minimizing the obstacles encountered and providing a personalized environment for learning.
In some cases cognitive disabilities can have motor control implications and consequently the traditional devices commonly used may not be the most appropriate for this population. In order to help developers choosing an adequate device, this paper also surveys and compares the most common devices used nowadays for serious games.
In this paper, we present an optimized implementation of automatic head direction extraction for a person placed in front of his webcam. The aim is to compute the different rotation angles of the head with a non-invasive and continuous tracking. Our method is based on 2D features tracking of the face with a low cost webcam. This information is associated to a set of points from a 3D head model by perspective-n-point solution to obtain pitch, roll and yaw. These results are then compared with a reference acquired with faceLAB, a robust markerless head tracker and eye tracking system.
Body representation disorders and disability in daily life
Patients with disorders of body representation may have disabilities in daily life activities. After right hemispheric stroke, anosognosia and neglect have predictive value on poor functional outcome and on discharge to home. A right hemispheric stroke is a significant risk factor for falling, and anosognosia and neglect can be associated to this risk. In daily life, body neglect is frequent with neglect of left limbs, neglect in dressing, but also buccal hemineglect. Apraxia for tool use after left hemispheric stroke and dressing apraxia, after right hemispheric stroke, cause disability in daily life activities.
One’s “attention” is said to appear in the visual behavior, i.e. eye and head movements and human brain is thought to set
visual attention area in the sight to get visual information efficiently. In head-eye coordination head movements are thought
to be controlled to fit the sight to visual attention area. Hence, setting of the attention area can appear in head movements.
In this study head and eye movements were measured using a wearable head and eye tracker system newly developed in this study,
and were studied whether the visual attention could be known from head movements or not. Results show that, head-movements
toward new attended area occur when human wants to switch the visual attention.
Games possess highly favourable attributes to bring to the field of neurorehabilitation by means of providing motivation and goal-directed exercise tasks. For the use of games to be effectively integrated in the commercial and clinical rehabilitation marketplace, it is necessary that a unified and comprehensive rehabilitation gaming platform be developed following principles of user-centered design. The needed platform must contain compatible modules for the planning and execution of treatment as well as progress assessment, and its development must take into consideration the needs and viewpoints of the involved stakeholders and the required supporting factors, including: patient, prescriber, therapist, care-provider, family, clinic, as well as supporting scientific evidence, technology, and policy. A proposed platform and needed components are explained and an example prototype rehabilitation platform is provided for discussion.
Video-games are becoming a common tool to guide patients through rehabilitation because of their power of motivating and engaging their users. Video-games may also be integrated into an infrastructure that allows patients, discharged from the hospital, to continue intensive rehabilitation at home under remote monitoring by the hospital itself, as suggested by the recently funded Rewire project.
Goal of this work is to describe a novel low cost platform, based on video-games, targeted to neglect rehabilitation.
The patient is guided to explore his neglected hemispace by a set of specifically designed games that ask him to reach targets, with an increasing level of difficulties. Visual and auditory cues helped the patient in the task and are progressively removed. A controlled randomization of scenarios, targets and distractors, a balanced reward system and music played in the background, all contribute to make rehabilitation more attractive, thus enabling intensive prolonged treatment.
Results from our first patient, who underwent rehabilitation for half an hour, for five days a week for one month, showed on one side a very positive attitude of the patient towards the platform for the whole period, on the other side a significant improvement was obtained. Importantly, this amelioration was confirmed at a follow up evaluation five months after the last rehabilitation session and generalized to everyday life activities.
Such a system could well be integrated into a home based rehabilitation system.
Coverage includes- David "RM" Michael has been a successful independent software developer for over 10 years, working in a variety of industries, including video games. He is the owner of DavidRM Software (www.davidrm.com) and co-owner of Samu Games (www.samugames.com). Michael is the author of The Indie Game Development Survival Guide, and his articles about game design, development, and the game development industry have appeared on GameDev.net (www.gamedev.net) and in the book Game Design Perspectives. His blog about independent games, serious games, and independent software is Joe Indie (www.joeindie.com). Sande Chen has been active in the gaming industry for over five years. She has written for mainstream and industry publications, including Secrets of the Game Business, and was a speaker at the 2005 Game Developers Conference. Her past game credits include Independent Games Festival winner Terminus, Scooby-Doo, and JamDat Scrabble. Chen holds dual degrees in economics and in writing and humanistic studies from the Massachusetts Institute of Technology, an M.Sc. in economics from the London School of Economics, and an M.F.A. in cinema-television from the University of Southern California. In 1996, she was nominated for a Grammy in music video direction. She currently works as a freelance writer/game designer. Covers techniques to make entertainment-oriented games richer and provide a deeper experience. The focus on serious games continues to grow--from coverage in the media to conferences and buzz within the game development community. Provides an overview of the major markets for serious games, including current examples and future anticipation.
Neurorehabilitation is based on the assumption that motor learning contributes to motor recovery after injury. However, little is known about how learning itself is affected by brain injury, how learning mechanisms interact with spontaneous biological recovery, and how best to incorporate learning principles into rehabilitation training protocols. Here we distinguish between two types of motor learning, adaptation and skill acquisition, and discuss how they relate to neurorehabilitation. Functional recovery can occur through resolution of impairment (reacquisition of premorbid movement patterns) and through compensation (use of alternative movements or effectors to accomplish the same goal); both these forms of recovery respond to training protocols. The emphasis in current neurorehabilitation practice is on the rapid establishment of independence in activities of daily living through compensatory strategies, rather than on the reduction of impairment. Animal models, however, show that after focal ischemic damage there is a brief, approximately 3-4-week, window of heightened plasticity, which in combination with training protocols leads to large gains in motor function. Analogously, almost all recovery from impairment in humans occurs in the first 3 months after stroke, which suggests that targeting impairment in this time-window with intense motor learning protocols could lead to gains in function that are comparable in terms of effect size to those seen in animal models.
Effective stroke rehabilitation must be early, intensive and repetitive, which can lead to problems with patient motivation
and engagement. The design of video games, often associated with good user engagement, may offer insights into how more effective
systems for stroke rehabilitation can be developed. In this paper we identify game design principles for upper limb stroke
rehabilitation and present several games developed using these principles. The games use low-cost video-capture technology
which may make them suitable for deployment at home. Results from evaluating the games with both healthy subjects and people
with stroke in their home are encouraging.
Hemineglect is a difficult neurologic condition to rehabilitate. It arises predominantly from right brain injury, and manifests heterogeneously in clinical deficits such as poor visual exploration to the left, inaccurate assessment of the midpoint of a line, left limb hypokinesis, and anosognosia. Most of the cognitive dysfunction produced by hemineglect is because of an asymmetric distribution of attention, either with respect to extrapersonal space or to an object being viewed. Many treatments draw on hemineglect theory to attempt to mediate the basic asymmetry of attention.
Treatment approaches can be divided into 2 main categories. Extrinsic or "top-down" approaches require active participation of the patient under the guidance of a therapist. The most common approach of this type is visual scanning therapy in which the patient is continually instructed to move the gaze leftward into the neglected space. Intrinsic or "bottom-up" approaches manipulate stimulus characteristics, sensory input, or the brain directly in an attempt to alter the interhemispheral attentional imbalance. Examples of this approach include vestibular stimulation of the left side, sensory activation of the left limb, and transcranial magnetic stimulation of the overactive left hemisphere. Combined approaches such as prism adaptation have also shown good results.
Hemineglect is a complicated disorder that poses challenges to treatment. A paucity of clinical trial evidence limits our ability to extrapolate experimental mediation of hemineglect to globally improved functioning. Nonetheless, many treatment approaches appear promising. Underlying neuroscience may help guide future treatment approaches.
The capacity to estimate the head pose of another person is a common human ability that presents a unique challenge for computer vision systems. Compared to face detection and recognition, which have been the primary foci of face-related vision research, identity-invariant head pose estimation has fewer rigorously evaluated systems or generic solutions. In this paper, we discuss the inherent difficulties in head pose estimation and present an organized survey describing the evolution of the field. Our discussion focuses on the advantages and disadvantages of each approach and spans 90 of the most innovative and characteristic papers that have been published on this topic. We compare these systems by focusing on their ability to estimate coarse and fine head pose, highlighting approaches that are well suited for unconstrained environments.
The aim of this study was to determine the prevalence of stroke survivors in a health district population aged 55 years and over.
This was a point prevalence study using two-stage postal questionnaires sent to an age stratified random sample of the population.
A district health authority in northern England with a resident population of 723,000.
Altogether 18,827 residents aged 55 years or over.
Prevalence was found to increase with age and, apart from the very elderly, males had a higher prevalence than females. Overall prevalence was found to be 46.8/1,000 (95% CI 42.5, 51.6). 23% of respondents reported full recovery from stroke. Cognitive impairments (33%), problems with lower limbs (33% for right leg; 27% for left leg) and speech difficulties (27%) were the most common residual impairments.
Current guidelines to purchasers on the provision of services to those who have had a stroke may under-estimate prevalence rates by as much as 50%. This could lead to a shortfall in provision of services designed to support people in the months and years following their stroke.
The aim was to study the role of visual neglect in acute right hemisphere brain infarct as a predictor of poor functional outcome during the first year after stroke. In particular, we were interested in the additional value of neglect measures besides hemiparesis, hemianopia, cognitive deficits and age.
A consecutive series of 57 patients with a neuroradiologically verified right hemisphere infarct was examined within 10 days of the stroke. Fifty patients were followed up for 1 year. Neglect was measured with the Conventional and the Behavioural subtests of the Behavioural Inattention Test (BITC and BITB, respectively). The predictors were determined at the 10-day examination. Functional outcome was assessed 3, 6 and 12 months after the onset with the Frenchay Activities Index.
Neglect in BITB was the best single predictor, which together with high age formed the best combination of predictors for poor functional outcome at each follow-up. Hemiparesis was also included in this prediction model at the 3-month follow-up, but hemianopia, BITC, or visuoconstructional and memory deficits showed no additional predictive value. However, neglect usually recovered soon. When neurological and cognitive deficits were assessed at the same time as the outcome, hemiparesis rather than neglect was the strongest correlate of poor outcome.
Neglect in acute stroke is an important predictor of poor functional recovery. Residual neglect, which could be compensated in the follow-up tests, may nevertheless restrict patients' real-life activities and hobbies.
Axinesis rehabilitation technologies
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Assessment of motor impairments in children with cerebral palsy using a rehabilitation robot and serious game exercise
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Conception et optimisation d'un robot de reeducation neuromotrice du membre superieur avec compensation active de la gravite
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Effective game use in neurorehabilitation: user-centered perspectives
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