Background: Virtual reality (VR) has the potential to provide intensive, repetitive, and task-oriented training, and game-based therapy can enhance patients’ motivation and enjoyment.
Objective: The objective of the present study was to develop a mobile game-based upper extremity VR program for patients who have experienced stroke, and to evaluate the feasibility and effectiveness of the program.
Methods: This randomized, double-blind, controlled trial included 24 patients with ischemic stroke. The intervention group (n = 12) received 30 min of conventional occupational therapy (OT) and 30 min of the mobile upper extremity rehabilitation program using a smartphone and a tablet PC (MoU-Rehab). The controls (n = 12) received conventional OT alone for 1 h per day. Rehabilitation consisted of 10 sessions of therapy, 5 days per week, for 2 weeks. The outcome measures (Fugl−Meyer Assessment of the upper extremity [FMA-UE], Brunnström stage [B-stage] for the arm and the hand, manual muscle testing [MMT], modified Barthel index [MBI], EuroQol-5 Dimension [EQ-5D], and Beck Depression Inventory [BDI]) were assessed at the beginning and end of treatment, and at 1 month. User satisfaction was evaluated by a questionnaire.
Results: A greater improvement in the FMA-UE, B-stage, and MMT was found after treatment with the MoU-Rehab than with conventional therapy. The extent of improvements in the MBI, EQ-5D, and BDI was not significantly different between the two groups. Patients in the experimental group completed the 2-weeks treatment without adverse effects, and they were generally satisfied with MoU-Rehab.
Conclusion: This mobile game-based VR rehabilitation program appears to be feasible and effective for promoting upper limb recovery after ischemic stroke.
AryaK.N., VermaR., GargR.K., SharmaV.P., AgarwalM., & AggarwalG.G. (2012). Meaningful task-specific training (MTST) for stroke rehabilitation: A randomized controlled trial. Topics in Stroke Rehabilitation, 19(3), 193–211.
2.
BoydL.A., VidoniE.D., & WesselB.D. (2010). Motor learning after stroke: Is skill acquisition a prerequisite for contralesional neuroplastic change?. Neuroscience Letters, 482(1), 21–25.
3.
BrooksR., RabinR., & De CharroF. (2013). The measurement and valuation of health status using EQ-5D: A European perspective: Evidence from the EuroQol BIOMED Research Programme: Springer Science & Business Media.
4.
BrunnströmS. (1970), Movement therapy in hemiplegia: A neurophysiological approach (1st ed.). New York: Medical Dept.
5.
BrunnstromS. (1966). Motor testing procedures in hemiplegia: Based on sequential recovery stages. Physical Therapy in Sport, 46(4), 357–375.
6.
ChangY.-J., ChenS.-F., & HuangJ.-D. (2011). A Kinect-based system for physical rehabilitation: A pilot study for young adults with motor disabilities. Research in Developmental Disabilities, 32(6), 2566–2570.
7.
ChenM.H., HuangL.L., LeeC.F., HsiehC.L., LinY.C., LiuH., … LuW.S. (2015). A controlled pilot trial of two commercial video games for rehabilitation of arm function after stroke. Clinical Rehabilitation, 29(7), 674–682.
8.
ChenP., LinK.-C., LiingR.-J., WuC.-Y., ChenC.-L., & ChangK.-C. (2015). Validity, responsiveness, and minimal clinically important difference of EQ-5D-5L in stroke patients undergoing rehabilitation. Quality of Life Research1–12.
9.
DworkinR.H., TurkD.C., WyrwichK.W., BeatonD., CleelandC.S., FarrarJ.T., … ZavisicS. (2008). Interpreting the clinical importance of treatment outcomes in chronic pain clinical trials: IMMPACT recommendations. The Journal of Pain, 9(2), 105–121.
10.
EdmansJ., GladmanJ., HiltonD., WalkerM., SunderlandA., CobbS., … ThomasS. (2009). Clinical evaluation of a non-immersive virtual environment in stroke rehabilitation. Clinical Rehabilitation, 23(2), 106–116.
11.
GebruersN., VanroyC., TruijenS., EngelborghsS., & De DeynP.P. (2010). Monitoring of physical activity after stroke: A systematic review of accelerometry-based measures. Archives of Physical Medicine and Rehabilitation, 91(2), 288–297.
12.
GladstoneD.J., DanellsC.J., & BlackS.E. (2002). The fugl-meyer assessment of motor recovery after stroke: A critical review of its measurement properties. Neurorehabilitation and Neural Repair, 16(3), 232–240.
13.
GreshamG.E., FitzpatrickT.E., WolfP.A., McNamaraP.M., KannelW.B., & DawberT.R. (1975). Residual disability in survivors of stroke–the Framingham study. The. New England Journal of Medicine, 293(19), 954–956.
14.
HendersonA., Korner-BitenskyN., & LevinM. (2007). Virtual reality in stroke rehabilitation: A systematic review of its effectiveness for upper limb motor recovery. Topics in Stroke Rehabilitation, 14(2), 52–61.
15.
HsiehY.-W., WangC.-H., WuS.-C., ChenP.-C., SheuC.-F., & HsiehC.-L. (2007). Establishing the minimal clinically important difference of the Barthel Index in stroke patients. Neurorehabilitation and Neural Repair, 21(3), 233–238.
16.
JooL.Y., YinT.S., XuD., ThiaE., ChiaP.F., KuahC.W.K., & HeK.K. (2010). A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke. Journal of Rehabilitation Medicine, 42(5), 437–441.
17.
JungH.Y., ParkB.K., ShinH.S., KangY.K., PyunS.B., PaikN.J., … HanT.R. (2007). Development of the Korean version of Modified Barthel Index (K-MBI): Multi-center study for subjects with stroke. Journal of Korean Academy of Rehabilitation Medicine, 31(3), 283–297.
18.
KendallP.C., HollonS.D., BeckA.T., HammenC.L., & IngramR.E. (1987). Issues and recommendations regarding use of the Beck Depression Inventory. Cognitive Therapy and Research, 11(3), 289–299.
19.
LanghorneP., CouparF., & PollockA. (2009). Motor recovery after stroke: A systematic review. The Lancet Neurology, 8(8), 741–754.
20.
LimH., ChoiY.-H., PaikN.-J., & KuJ. (2015). Development and Clinical Evaluation of the Upper Extremity Rehabilitation Game Program for Patients with Upper Extremity Hemiplegia After Stroke Using Smartphone: Preliminary Study. Journal of Biomedical Engineering Research, 36, 155–161.
21.
LinK.-c., HsiehY.-w., WuC.-y., ChenC.-l., JangY., & LiuJ.-s. (2009). Minimal detectable change and clinically important difference of the Wolf Motor Function Test in stroke patients. Neurorehabilitation and Neural Repair, 23(5), 429–434.
22.
LohseK.R., HildermanC.G., CheungK.L., TatlaS., & Van der LoosH.F. (2014). Virtual reality therapy for adults post-stroke: A systematic review and meta-analysis exploring virtual environments and commercial games in therapy. PLoS One, 9(3), e93318.
23.
MaH.-I., HwangW.-J., FangJ.-J., KuoJ.-K., WangC.-Y., LeongI.-F., & WangT.-Y. (2011). Effects of virtual reality training on functional reaching movements in people with Parkinson’s disease: A randomized controlled pilot trial. Clinical Rehabilitation, 25(10), 892–902.
24.
Narayan AryaK., VermaR., & GargR. (2011). Estimating the minimal clinically important difference of an upper extremity recovery measure in subacute stroke patients. Topics in Stroke Rehabilitation, 18(Supplement-1), 599–610.
25.
ReitererV., SauterC., KlöschG., LalouschekW., & ZeitlhoferJ. (2008). Actigraphy–a useful tool for motor activity monitoring in stroke patients. European Neurology, 60(6), 285–291.
26.
RichardsL., & PohlP. (1999). Therapeutic interventions to improve upper extremity recovery and function. Clinics in Geriatric Medicine, 15(4), 819–832.
27.
SaposnikG., LevinM., & Outcome Research Canada Working, G. (2011). Virtual reality in stroke rehabilitation: A meta-analysis and implications for clinicians. Stroke, 42(5), 1380–1386.
28.
SaposnikG., MamdaniM., BayleyM., ThorpeK.E., HallJ., CohenL.G., ...… Group, E. S. G. f. t. S. O. R. C. W. (2010). Effectiveness of Virtual Reality Exercises in STroke Rehabilitation (EVREST): Rationale, design, and protocol of a pilot randomized clinical trial assessing the Wii gaming system. International Journal of Stroke, 5(1), 47–51.
29.
SaposnikG., TeasellR., MamdaniM., HallJ., McIlroyW., CheungD., ...… Stroke Outcome Research Canada Working G (2010). Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: A pilot randomized clinical trial and proof of principle. Stroke, 41(7), 1477–1484.
30.
SegalM.E., & WhyteJ. (1997). Modeling case mix adjustment of stroke rehabilitation outcomes. Rehabilitation, 76(2), 154–161.
31.
SinH., & LeeG. (2013). Additional virtual reality training using Xbox Kinect in stroke survivors with hemiplegia.&. Rehabilitation, 92(10), 871–880.
32.
TaubE., MillerN.E., NovackT.A., CookE.W.3rd, FlemingW.C., NepomucenoC.S., … CragoJ.E. (1993). Technique to improve chronic motor deficit after stroke. Archives of Physical Medicine and Rehabilitation, 74(4), 347–354.
33.
VenugopalanJ., ChengC., StokesT.H., & WangM.D. (2013). Kinect-based rehabilitation system for patients with traumatic brain injury. Paper presented at the Engineering in Medicine and Biology Society (EMBC), 35th Annual International Conference of the IEEE.
