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Feasibility of a Customized, In-Home, Game-Based Stroke Exercise Program Using the Microsoft Kinect® Sensor

Feasibility of a Customized, In-Home, Game-Based Stroke Exercise Program Using the Microsoft... International Journal of Telerehabilitation • telerehab.pitt.edu FEASIBILITY OF A CUSTOMIZED, IN-HOME, GAME- BASED STROKE EXERCISE PROGRAM USING THE MICROSOFT KINECT® SENSOR 1 2 RACHEL PROFFITT, OTD, OTR/L , BELINDA LANGE, BSC, BPHYSIO (HONS), PHD MRS. T.H. CHAN DIVISION OF OCCUPATIONAL SCIENCE & OCCUPATIONAL THERAPY, UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CA, USA INSTITUTE FOR CREATIVE TECHNOLOGIES, UNIVERSITY OF SOUTHERN CALIFORNIA, PLAYA VISTA, CA, USA ABSTRACT The objective of this study was to determine the feasibility of a 6-week, game-based, in-home telerehabilitation exercise program using the Microsoft Kinect® for individuals with chronic stroke. Four participants with chronic stroke completed the intervention based on games designed with the customized Mystic Isle software. The games were tailored to each participant’s specific rehabilitation needs to facilitate the attainment of individualized goals determined through the Canadian Occupational Performance Measure. Likert scale questionnaires assessed the feasibility and utility of the game -based intervention. Supplementary clinical outcome data were collected. All participants played the games with moderately high enjoyment. Participant feedback helped identify barriers to use (especially, limited free time) and possible improvements. An in-home, customized, virtual reality game intervention to provide rehabilitative exercises for persons with chronic stroke is practicable. However, future studies are necessary to determine the intervention’s impact on participant function, activity, and involvement. Keywords: Home exercise program, motivation, stroke, virtual reality Stroke is the leading cause of serious, long-term a list of exercises with illustrated instructions that patients disability in the United States. Every year, approximately must read, understand, and implement on their own. 800,000 people experience a new or recurrent stroke (Go et Adherence to these self-guided programs is low because al., 2013). After an initial stroke, varying degrees of factors including fatigue, poor health, lack of motivation, and spontaneous recovery can occur; some survivors are able to musculoskeletal issues often prevent patients from either return to their usual activities of daily living (ADLs) initiating or maintaining the exercise programs (Jurkiewicz et (Hartman-Maeir et al., 2007). Typically, six months after the al., 2011; Payne et al., 2001; Shaughnessy et al., 2006). initial event, a large percentage of individuals experience Further, among those who implement self-guided programs, deficits including hemiparesis (50%) and dependence in adherence is often very difficult to quantify or assess ADLs (26%) (Go et al., 2013). In these cases, inpatient because typically patients do not consistently or accurately rehabilitation programs are the primary means to address record their progress. and improve impaired physiological, motor, and cognitive To mitigate barriers to implementing in-home exercise functioning (Woodson, 2008). Unfortunately, for those with programs, it is necessary to provide patients with tools that residual deficits in functioning, only 31% reported receiving motivate them to practice exercise activities in a safe, outpatient rehabilitation (Centers for Disease Control, 2007). structured, and easily monitored manner. A novel way to In-home exercise programs are a viable option for achieve this in the area of stroke rehabilitation is through the stroke survivors who require continued rehabilitation to use of interactive technologies such as video games and generate improvements in function; for those who require virtual reality (VR). The use of interactive technologies and regular exercise and daily physical activity to maintain gains VR for exercise and rehabilitation has expanded rapidly over and prevent declines after outpatient rehabilitation; and for the past 15 years. Systematic reviews and clinical trial data patients whose insurance coverage for structured suggest that VR technology can be used to improve motor rehabilitation has ended. These programs typically consist of skill rehabilitation for a range of functional deficits International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu (Adamovich et al., 2005; Henderson et al., 2007; Merians et Table 1. Characteristics of the Participants al., 2002; Stewart et al., 2007). However, the technologies Characteristics Participant and systems described in these reviews are limited because they are expensive, not portable into the home setting, or 1 2 3 4 use outdated technology and software. Gender M F F M To address these limitations, we have developed a VR Age (years) 55 54 64 56 rehabilitation software called Mystic Isle that combines the customized nature of rehabilitation with components of self- Side of Paresis L R N/A L determination theory (Ryan & Deci, 2000; Sheldon & Filak, 2008) and game engagement (Przybylski et al., 2010). This highly specialized rehabilitation software, in combination Because of your stroke, do you have any difficulty with: with a high-fidelity movement sensor, the Microsoft Kinect® camera, provides the following benefits that are superior to Mobility, 13 6 2 13 those obtained through other currently available VR systems strength, and fine for rehabilitation: (1) targeted improvements in physiological, motor skills motor, and/or cognitive performance; (2) customization to (X/36)* patient treatment goals, preferences, and need; (3) Activities of Daily 7 0 0 4 individualized therapy without requiring an intensive one-on- Living (ADLs) one time commitment by a therapist; (4) easily transportable (X/21)* into the home, providing an expedient and practical mode of ongoing care; (5) immediate feedback to the patient; and (6) Instrumental 4 1 8 3 a record of quantitative performance data easily accessed Activities of Daily by the therapist. Further, Mystic Isle allows therapists with Living (IADLs) little to no programming skills to modify the delivery (X/18)* parameters for participant interaction across a variety of Fugl-Meyer 24 45 66 25 relevant dimensions and to easily extract and view Assessment- performance data (Lange et al., 2011; Lange et al., 2012). Upper Extremity The primary purpose of this study was to explore the feasibility and utility of Mystic Isle as a 6-week, game-based, Note. *Higher score = greater difficulty in-home exercise program for individuals with chronic Participant 1 had left hemiparesis in both the arm stroke. A secondary purpose was to provide a preliminary (moderate to severe upper extremity motor function deficits) assessment of the impact of game involvement on clinical and leg that manifested as mild to moderate mobility outcomes. impairments, mild impact on ADL performance, and minimal The Institutional Review Board of the University of impact on instrumental activities of daily living (IADL) Southern California approved this study. performance. Participant 4 had a similar clinical presentation; however, he reported that his hemiparesis had a mild impact on his performance of IADLs. With hemiparesis on her right side (mild deficits in upper extremity motor function), Participant 2 reported a mild METHODS impact on her mobility and negligible impact on her performance of ADLs and IADLs. None of these participants had detectable cognitive deficits. In contrast, Participant 3 had no motor deficits due to stroke, but demonstrated STUDY PARTICIPANTS expressive aphasia and cognitive deficits that moderately impacted her performance of IADLs Four individuals with chronic stroke participated in this feasibility study. Participants were chosen based on the following criteria: (1) had sustained a stroke ≥ 6 months prior th to study commencement; (2) ability to read English at a 6 INTERVENTION grade level; and (3) possess in-home internet connection. Study candidates were excluded if medical contraindications (e.g., seizure disorders) prevented them from playing video MYSTIC ISLE GAME games. Table 1 depicts the participants’ demographic and clinical characteristics. The Mystic Isle software (Lange et al., 2012) runs on a standard desktop or laptop PC. The Microsoft Kinect® International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu camera connects to the computer via USB and serves as components are designed to be easy to assemble and the input sensor that detects and tracks a player’s joint navigate. movements in 3D space (Figure 1). The software and Figure 1. Mystic Isle game set-up in a participant's home. The participant is seated and reaching forward with his right arm. Visible are the monitor, the Kinect sensor, the laptop, and the wireless mouse. Designed for use by an occupational therapist (OT), the generated five treatment goals. The OT subsequently software contains a control panel through which the game customized the game and calibrations in accord with the can be calibrated and modified based on the player’s assessment findings (Table 2). For example, Participant 2 physical rehabilitation and exercise treatment plan needs identified a goal of being able to kneel and reach forward to and goals. For example, it allows for tailoring of parameters clean her bathtub. In the custom calibration, participant 2 such as game timing (for rapid game start), physical tasks, kneeled on the ground and reached forward for virtual visual preferences, repetition number, and challenge level. objects during game interaction. This challenged and helped One additional feature is that the preferences and restore the specific abilities necessary to complete the calibrations can be updated as needed throughout the functional task of cleaning the bathtub: trunk control, core course of the intervention. strength, and reaching. Each week the OT reviewed the adequacy of the game settings and calibrations in relation to automated progress report findings. When needed, she GAME SELECTION AND CALIBRATION made changes to game settings and calibrations based on her clinical judgment and on participant progress by An OT administered the Canadian Occupational remotely logging-in to the participant’s home-based Performance Measure (COPM) (Law, 1998) to identify each computer. participant’s occupational performance problems and International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu Table 2. Canadian Occupational Performance Measure (COPM) Goals and Associated Game Sessions for Each Participant Participant COPM Goal Game Session Exercises 1 Walk on uneven ground 1. Step up onto platform 2. Reach with right arm 3. Reach with both arms + leg extension exercises Fold laundry 1. Reach with left arm 2. Reach with both arms while standing and then sitting Fasten zippers 1. Reach with left arm while standing Find items in a crowded 1. Play memory games during sitting and standing tasks environment Read faster 1. Perform matching games while sitting and standing tasks 2 Chop food 1. Reach with right arm Kneel to clean bathtub 1. Reach with left arm in tall kneeling 2. Squat 3. Sit-to-stand Use railing while going 1. Step forward up/down stairs 2. Reach in standing position Remember names 1. Play Memory games while stepping forward Put hair in a ponytail 1. High reach with right arm 3 Reading 1. Remember words 2. Choose antonym See items on left side of 1. Dual-task game visual field 2. Sort objects Communicate with others 1. Recall words Manage money during 1. Add two numbers transactions 2. Match numbers 3. Remember numbers Maintain focus for extended 1. Dual-task game for extended period of time (session duration > periods of time 10 minutes) 4 Fold clothes 1. Reach with left and right arm in standing Walk for longer periods of 1. Reach both arms in standing for extended period of time time (session duration > 5 minutes) Reaching with both arms while standing on compliant surface Walk on sand at beach 1. Reach alternately with left and right arms while standing on compliant surface Stabilize items using 1. Reach with left arm impaired side Button pants 1. Reach with left arm International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu CLINICAL IMPACT (SECONDARY IN-HOME SETUP OUTCOMES) Two researchers and the OT visited each participant’s Upper extremity function, perceived activity home to assist in setting up the Mystic Isle software, performance, balance confidence, and quality of life were monitors, Microsoft Kinect® sensor, and computer assessed at baseline, as well as 2 weeks later (i.e., just prior peripherals. The in-home setup location was determined in to intervention commencement, and following intervention). cooperation with each participant and, if necessary, his/her Upper extremity function was assessed with the Fugl-Meyer family members/caregivers. The location was required to: Upper Extremity Assessment (Fugl-Meyer, Jassko, Leyman, (1) provide adequate space for game equipment and Olsson, & Stenlind, 1975). This performance-based movement and (2) allow for Internet connectivity or wireless assessment is well validated and reliable for the chronic Internet access. In addition to instructing participants in how stroke population (Duncan, Propst, & Nelson, 1983; Hsieh et to set up the technology, researchers also taught them how al., 2009). Perceived activity performance was assessed to troubleshoot technical issues, navigate the gaming menu, with the Canadian Occupational Performance Measure and load intervention tasks. (COPM) (Law, 1998). Structured as an interview and self- rating of performance and satisfaction with performance, the COPM has high validity and reliability for persons with INTERVENTION DURATION chronic stroke (Cup, Scholte op Reimer, Thijssen, & van Kuyk-Minis, 2003). Balance confidence was assessed Each participant was instructed to achieve at least 4 through a self-report measure, the Activities-Specific hours of game play per week over the 6-week intervention Balance Confidence Scale (Botner, Miller, & Eng, 2005). An period. The duration of each game play session was left to additional self-report measure, the Stroke-Specific Quality of the participant’s discretion. For this reason, game play Life Scale (Williams, Weinberger, Harris, Clark, & Biller, session duration varied among participants. None of the 1999), was utilized to assess stroke-related quality of life. study participants were receiving therapy outside of this Both the Activities-specific Balance Confidence Scale and study. the Stroke-Specific Quality of Life Scale have good validity and reliability for the chronic stroke population (Botner, Miller, & Eng, 2005; Lin et al., 2010). OUTCOMES STATISTICAL ANALYSIS FEASIBILITY AND USABILITY OF THE The results of the Game Experience Questionnaire and MYSTIC ISLE GAME (PRIMARY OUTCOMES) System Usability Scale were expressed as a distribution of Likert scale responses for each participant. The semi- The primary outcomes of this study were the usability structured interview data were analyzed using a grounded and feasibility of the Mystic Isle in-home exercise program theory approach (Corbin & Strauss, 2008). Two independent for persons with chronic stroke. These outcomes were researchers coded the data to detect emerging themes. assessed at post-intervention only using an embedded They also met frequently for inter-coder agreement checks. design, mixed-methods approach (Creswell, Klassen, Plano The quantitative data were then synthesized with the Clark, & Smith, 2011). Feasibility and usability were qualitative data to substantiate emerging themes. For the quantitatively measured using the Game Experience clinical evaluation data, baseline and pre-intervention scores Questionnaire, derived from IBM measures of system for each measure were averaged to produce a pre- usability (Lewis, 1995), and the System Usability intervention score for each study participant. The differences Questionnaire (Bangor, Kortum, & Miller, 2009). Both in the participants’ post- and pre-intervention scores were instruments utilize a 5-point Likert scale rating. Qualitative compared to the Minimal Detectable Change (MDC) score assessment of feasibility and usability was determined via a for each clinical assessment tool. The MDC was used for semi-structured interview that focused on the following: (1) this study because it provides a criterion for the smallest the attractiveness and appeal of the Mystic Isle intervention; amount of change in an outcome measure that corresponds (2) system integration, including technology set-up, into the to perceptible change in ability or functional status. home; and (3) the rehabilitative potential of Mystic Isle. Additionally, the Mystic Isle software provided data on the exact number of minutes each participant spent playing the game each day. International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu Participant 2 averaged 3.5 hours/week, whereas Participant RESULTS 3 only averaged 1 hour/week. All participants found it difficult to follow the 4-hour recommended length of game- playing each week due to busy schedules or previous commitments. For example, all participants were regularly PARTICIPANT EXPERIENCE AND engaged in activities in and outside of the home such as SYSTEM USABILITY yoga, book club, and stroke support groups. In the words of one participant: “I was just trying to figure out when to get it Three out of four participants rated the system as in because I am so busy.” Additionally, participants reported “usable” or “very usable.” This was evidenced by their that they were often fatigued or stressed after a full day of average ratings of 1.46, 2.19, and 2.76 on the Game activity: “I just feel so overwhelmed sometimes, [with] all the Experience Questionnaire and System Usability Scale, things I got to do.” To overcome this barrier, some of the where 1 = very usable, and 5 = not usable at all. Participant participants attempted to play in the morning before going 3 had an average rating of 4.42 due to reported difficulty out or divided the time invested into multiple short durations understanding the directions to start the game on the laptop. throughout the day. Seventy-five percent of game play Despite the therapist and study team’s best efforts to include sessions across participants occurred exclusively in the visual cues and reminders, Participant 3 experienced afternoon or evening. frustration loading the game and navigating through the three steps required to begin playing. Moreover, Participant For Participant 3, accessing the game on the computer 3 also continued to attempt playing the game without a (e.g., finding the icon to click, following the steps to log-in) caregiver present to load it or to troubleshoot, even though presented a barrier to play. Participant 3 was able to play the therapist and study team recommended she include a the game with verbal cues when the OT was present in the caregiver in the process. Participant 4 experienced minor home; however at other times, she did not use assistance technical issues but was able to resolve them during a from caregivers to load or play the game. Due to her phone call to the treating therapist or study team. Once the cognitive deficits, she had difficulty processing and following intervention was completed, participants identified factors directions, both written and pictorial. However, none of the that facilitated the use of Mystic Isle as an in-home participants mentioned the physical environment or physical intervention, identified barriers, and made suggestions for technology set-up as a barrier to use. future software improvements. SUGGESTIONS FOR FUTURE USE FACTORS THAT FACILITATED USE Participants provided the following feedback on how to Participants indicated they liked the customized aspect improve the Mystic Isle intervention: (1) Increasing the of the Mystic Isle. They claimed they were inspired to play amount of choice on the part of the player; (2) Including and enjoyed the games because they were tailored to help background music; (3) Providing more on-screen them achieve their particular goals. As one participant performance feedback; (4) Maintaining the on-screen stated, “It was fun when I could tailor a game to me.” The instructions, but allowing the player to progress in the game overall desire to improve and “get [their] bod[ies] and without having to read them; and (5) Adding an on-screen mind[s] better” was the main incentive for all participants. “Help” link for technical issues and troubleshooting. Further, they indicated that they appreciated having a variety of games to help them reach their goals and multiple means to improvement: “I enjoyed that they [Mystic Isle games] were [each] different.” Furthermore, the three CLINICAL EVALUATION participants without cognitive difficulties were additionally Participants 2 and 4 reported an increased ability in the motivated by the motor + cognitive challenge games. self-care domain on the Stroke-Specific Quality of Life scale (post- and pre-intervention differences of 4.0 and 9.0, respectively), which was greater than the MDC of 4.0. Participant 2 obtained an increased score in COPM BARRIERS satisfaction (a post- and pre-intervention difference of 2.4), Time management was the main barrier identified by which was greater than the MDC of 1.75. No scores on participants. On average, participants played 30 minutes per other clinical evaluation measures were greater than the day, 5 days per week; totaling 2.5 hours each week. MDC for each respective measure (Table 3). International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu Table 3. Results of Clinical Outcome Measures for Each Participant at Three Time Points Clinical Outcome Measure Baseline Pre Post 1 2 3 4 1 2 3 4 1 2 3 4 Fugl-Meyer Assessment- Upper Extremity (x/66) 24 45 66 25 24 44 66 28 24 42 66 33 Canadian Occupational Performance Measure Performance (x/10) 3.6 2.4 3.4 1.4 3.4 2.6 3.4 1.2 4.2 3.6 1.2 2 Satisfaction (x/10) 1 2 1.8 1 2.2 1.8 1.4 1 2.4 2.8 4 2.2 Activities-specific Balance Confidence Scale (%) 59.38 75.31 88.75 59.69 70.63 74.25 81.25 65.63 71.88 78.75 94.38 54.38 Stroke-specific Quality of Life Scale Energy (x/15) 7 15 6 13 6 15 11 14 8 15 15 11 Family Roles (x/15) 9 12 5 11 13 12 8 10 12 15 9 11 Language (x/25) 20 25 5 25 24 25 10 23 6 25 15 25 Mobility (x/30) 25 30 29 27 14 30 28 20 18 30 30 23 Mood (x/25) 13 24 13 24 20 23 9 21 22 25 16 21 Personality (x/15) 5 12 6 12 7 9 6 13 6 13 7 10 Self-Care (x/25) 12 24 23 24.5 14 24 19 21 22 22 25 21 Social Roles (x/25) 17 16 5 18 8 10 10 12 10 20 17 15 Thinking (x/15) 8 15 3 9 6 15 6 9 8 15 3 10 Upper Extremity Function (x/25) 12 23 20 13 14 20 20 9 14 24 21 11 Vision (x/15) 13 15 13 15 12 15 11 15 14 15 13 15 Work/Productivity (x/15) 14 8 9 8 8 13 9 9 6 9 9 10 Total (x/245) 155 219 137 199.5 146 211 147 176 146 228 180 183 International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu older, we found that Mystic Isle was described as lacking sufficient user-friendliness. The older adults in that study indicated they would be more likely to adopt the game- based intervention if the system was simpler, more intuitive, DISCUSSION and had an easy “push-button-start” (Proffitt & Lange, 2013). The primary purpose of this study was to explore the Currently, our investigative team is modifying the Mystic Isle feasibility and utility of a 6-week, game-based, in-home game based on this feedback. exercise program for persons with chronic stroke. Three of Although cognitive deficits and technological concerns the four participants were able to successfully use the impeded use in this study, the primary reason all study Mystic Isle intervention as evidenced by their ratings on participants did not achieve the 4-hour per week intervention usability scales and their subjective responses to open- goal was due to the additional activities in which they were ended interview questions. However, the hours invested by engaged. As stated earlier, participants claimed that they all participants fell short of the recommended time. could not devote sufficient time to the exercise program Participant 2 consistently completed the intervention for the because they were either too busy or simply overwhelmed most amount of time per week (3.5 hours/week for all 6 with all of the things they had to do. Some evidence weeks). She also experienced improvements in clinical suggests that, even though many persons with chronic evaluation measures outside of the MDC, but these stroke report returning to many of their pre-stroke activities, improvements were subjectively self-reported. Although the amount of time and effort required to complete these Participant 2 had higher baseline levels of function, the two activities often increases, even dramatically, in comparison participants with greater deficits in motor and ADL function to pre-stroke levels (Mayo, Wood-Dauphinee, Cote, Durcan, were still able to use the Mystic Isle game in their home. The & Carlton, 2002). For many stroke survivors, the motivation majority of recent studies investigating interventions for the to complete exercises and therapeutic interventions is chronic stroke population target persons much like strong, but having sufficient time to do so can be Participant 2 who have higher levels of motor function (i.e., problematic (Proffitt & Lange, 2013). Consequently, tailoring some hand movement and a score greater than 45 on the game sessions and exercises so that they can be completed Fugl-Meyer Assessment-Upper Extremity) (Combs, Kelly, with minimal effort and in short amounts of time is likely to Barton, Ivaska, & Nowak, 2010; Egan, Kessler, Laporte, facilitate adoption on an ongoing basis by stroke survivors. Metcalfe, & Carter, 2007; Pang, Eng, Dawson, McKay, & Harris, 2005). The results of this study suggest that it may Many studies have revealed that adherence in self- be feasible to implement an in-home intervention with stroke directed programs tends to be poor (Chen, Neufeld, Feely, & survivors with lower levels of motor and daily function. Skinner, 1999; Forkan et al., 2006; Jurkiewicz, Marzolini, & Oh, 2011). The studies by Forkan and colleagues (2006) Even with lower levels of motor and daily functioning, and Chen and colleagues (1999) utilized a common method the participants were able to use the in-home technological of tracking home exercise program adherence: an exercise intervention; however, poorer cognitive ability impeded log or report completed by the patient. Jurkiewicz and game engagement. As mentioned above, despite the OT’s colleagues (2011) did not report specific methods for efforts to remotely troubleshoot and provide reminders, tracking adherence; however they provided suggestions to cognitive deficits were found to be a significant barrier to increase adherence including increasing support from family Participant 3’s engagement in the game. It is unclear members and physicians. Suggestions provided by Chen whether ongoing caregiver support would have lessened or and colleagues (1999) included a link to the health belief even eliminated this problem. This finding suggests that as it model by suggesting that therapists ensure that patients feel stands, the Mystic Isle game may be most appropriate for confident in their abilities to complete the prescribed individuals who possess minimal cognitive deficits. In a exercises. This is linked to one of the central tenets of Self- future study, it may be helpful to determine minimum cut-off Determination Theory that underlies Mystic Isle: scores on the Mini Mental State Examination that are competence. Additionally, Forkan and colleagues (2006) predictive of successful adoption of the intervention. reported that the largest barrier to adherence in their study Even in the absence of cognitive deficits, the was change in health status, and the authors recommended technology itself in some instances proved difficult to use. return visits to the clinic to update the program. The For example, Participant 4, who suffered no cognitive advantage of using Microsoft Kinect® sensor technology in deficits, had issues starting and playing Mystic Isle including the home is that the OT (or any other care provider) can logging into the game and selecting the appropriate game remotely check progress and update the program without tasks. Consequently, he had to intermittently stop playing requiring the patient to spend precious time in travel to the the game to seek help from the study team, inadvertently clinic. Further, Mystic Isle provides an objective measure of impacting the frequency of use and revealing limitations of the amount of time a user plays a game, the number of using Mystic Isle as a self-directed intervention. Similarly, in repetitions a player achieves, along with other valid one of our recent studies involving older adults aged 65 or kinematic data (Fern’ndez-Baena, Susin, & Lligadas, 2012) International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu on performance. Not only are such reports helpful for Isle in improving motor function or performance of ADLs, treating therapists, they also create an incentive for persons larger trials must be conducted. with stroke to adhere to a program and improve on performance. In this regard, participants indicated that the combination of the customized nature of the games, the relationship of the exercises to self-identified goals, and the REFERENCES objective technologically-provided feedback were key to motivating them to stick to the program. Adamovich, S. V., Merians, A. S., Boian, R., Lewis, J. A., Tremaine, M., Burdea, G. S., ... & Poizner, H. 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International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu Stewart, J. C., Yeh, S. C., Jung, Y., Yoon, H., Whitford, M., Woodson, A. M. (2008). Stroke. In M. V. Radomski & C. A. Chen, S. Y., … & Winstein, C. J. (2007). Intervention to Trombly Latham (Eds.), Occupational Therapy for th enhance skilled arm and hand movements after stroke: Physical Dysfunction (6 ed). Maryland: Lippincott A feasibility study using a new virtual reality system. Williams & Wilkins. Journal of Neuroengineering & Rehabilitation, 4(21), e1-6. Williams, L. S., Weinberger, M., Harris, L. E., Clark, D. O., & Biller, J. (1999). Development of a stroke-specific quality of life scale. Stroke, 30, 1362-1369. International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Telerehabilitation Pubmed Central

Feasibility of a Customized, In-Home, Game-Based Stroke Exercise Program Using the Microsoft Kinect® Sensor

PROFFITT, RACHEL; LANGE, BELINDA
International Journal of Telerehabilitation , Volume 7 (2) – Nov 20, 2015
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10.5195/ijt.2015.6177
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International Journal of Telerehabilitation • telerehab.pitt.edu FEASIBILITY OF A CUSTOMIZED, IN-HOME, GAME- BASED STROKE EXERCISE PROGRAM USING THE MICROSOFT KINECT® SENSOR 1 2 RACHEL PROFFITT, OTD, OTR/L , BELINDA LANGE, BSC, BPHYSIO (HONS), PHD MRS. T.H. CHAN DIVISION OF OCCUPATIONAL SCIENCE & OCCUPATIONAL THERAPY, UNIVERSITY OF SOUTHERN CALIFORNIA, LOS ANGELES, CA, USA INSTITUTE FOR CREATIVE TECHNOLOGIES, UNIVERSITY OF SOUTHERN CALIFORNIA, PLAYA VISTA, CA, USA ABSTRACT The objective of this study was to determine the feasibility of a 6-week, game-based, in-home telerehabilitation exercise program using the Microsoft Kinect® for individuals with chronic stroke. Four participants with chronic stroke completed the intervention based on games designed with the customized Mystic Isle software. The games were tailored to each participant’s specific rehabilitation needs to facilitate the attainment of individualized goals determined through the Canadian Occupational Performance Measure. Likert scale questionnaires assessed the feasibility and utility of the game -based intervention. Supplementary clinical outcome data were collected. All participants played the games with moderately high enjoyment. Participant feedback helped identify barriers to use (especially, limited free time) and possible improvements. An in-home, customized, virtual reality game intervention to provide rehabilitative exercises for persons with chronic stroke is practicable. However, future studies are necessary to determine the intervention’s impact on participant function, activity, and involvement. Keywords: Home exercise program, motivation, stroke, virtual reality Stroke is the leading cause of serious, long-term a list of exercises with illustrated instructions that patients disability in the United States. Every year, approximately must read, understand, and implement on their own. 800,000 people experience a new or recurrent stroke (Go et Adherence to these self-guided programs is low because al., 2013). After an initial stroke, varying degrees of factors including fatigue, poor health, lack of motivation, and spontaneous recovery can occur; some survivors are able to musculoskeletal issues often prevent patients from either return to their usual activities of daily living (ADLs) initiating or maintaining the exercise programs (Jurkiewicz et (Hartman-Maeir et al., 2007). Typically, six months after the al., 2011; Payne et al., 2001; Shaughnessy et al., 2006). initial event, a large percentage of individuals experience Further, among those who implement self-guided programs, deficits including hemiparesis (50%) and dependence in adherence is often very difficult to quantify or assess ADLs (26%) (Go et al., 2013). In these cases, inpatient because typically patients do not consistently or accurately rehabilitation programs are the primary means to address record their progress. and improve impaired physiological, motor, and cognitive To mitigate barriers to implementing in-home exercise functioning (Woodson, 2008). Unfortunately, for those with programs, it is necessary to provide patients with tools that residual deficits in functioning, only 31% reported receiving motivate them to practice exercise activities in a safe, outpatient rehabilitation (Centers for Disease Control, 2007). structured, and easily monitored manner. A novel way to In-home exercise programs are a viable option for achieve this in the area of stroke rehabilitation is through the stroke survivors who require continued rehabilitation to use of interactive technologies such as video games and generate improvements in function; for those who require virtual reality (VR). The use of interactive technologies and regular exercise and daily physical activity to maintain gains VR for exercise and rehabilitation has expanded rapidly over and prevent declines after outpatient rehabilitation; and for the past 15 years. Systematic reviews and clinical trial data patients whose insurance coverage for structured suggest that VR technology can be used to improve motor rehabilitation has ended. These programs typically consist of skill rehabilitation for a range of functional deficits International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu (Adamovich et al., 2005; Henderson et al., 2007; Merians et Table 1. Characteristics of the Participants al., 2002; Stewart et al., 2007). However, the technologies Characteristics Participant and systems described in these reviews are limited because they are expensive, not portable into the home setting, or 1 2 3 4 use outdated technology and software. Gender M F F M To address these limitations, we have developed a VR Age (years) 55 54 64 56 rehabilitation software called Mystic Isle that combines the customized nature of rehabilitation with components of self- Side of Paresis L R N/A L determination theory (Ryan & Deci, 2000; Sheldon & Filak, 2008) and game engagement (Przybylski et al., 2010). This highly specialized rehabilitation software, in combination Because of your stroke, do you have any difficulty with: with a high-fidelity movement sensor, the Microsoft Kinect® camera, provides the following benefits that are superior to Mobility, 13 6 2 13 those obtained through other currently available VR systems strength, and fine for rehabilitation: (1) targeted improvements in physiological, motor skills motor, and/or cognitive performance; (2) customization to (X/36)* patient treatment goals, preferences, and need; (3) Activities of Daily 7 0 0 4 individualized therapy without requiring an intensive one-on- Living (ADLs) one time commitment by a therapist; (4) easily transportable (X/21)* into the home, providing an expedient and practical mode of ongoing care; (5) immediate feedback to the patient; and (6) Instrumental 4 1 8 3 a record of quantitative performance data easily accessed Activities of Daily by the therapist. Further, Mystic Isle allows therapists with Living (IADLs) little to no programming skills to modify the delivery (X/18)* parameters for participant interaction across a variety of Fugl-Meyer 24 45 66 25 relevant dimensions and to easily extract and view Assessment- performance data (Lange et al., 2011; Lange et al., 2012). Upper Extremity The primary purpose of this study was to explore the feasibility and utility of Mystic Isle as a 6-week, game-based, Note. *Higher score = greater difficulty in-home exercise program for individuals with chronic Participant 1 had left hemiparesis in both the arm stroke. A secondary purpose was to provide a preliminary (moderate to severe upper extremity motor function deficits) assessment of the impact of game involvement on clinical and leg that manifested as mild to moderate mobility outcomes. impairments, mild impact on ADL performance, and minimal The Institutional Review Board of the University of impact on instrumental activities of daily living (IADL) Southern California approved this study. performance. Participant 4 had a similar clinical presentation; however, he reported that his hemiparesis had a mild impact on his performance of IADLs. With hemiparesis on her right side (mild deficits in upper extremity motor function), Participant 2 reported a mild METHODS impact on her mobility and negligible impact on her performance of ADLs and IADLs. None of these participants had detectable cognitive deficits. In contrast, Participant 3 had no motor deficits due to stroke, but demonstrated STUDY PARTICIPANTS expressive aphasia and cognitive deficits that moderately impacted her performance of IADLs Four individuals with chronic stroke participated in this feasibility study. Participants were chosen based on the following criteria: (1) had sustained a stroke ≥ 6 months prior th to study commencement; (2) ability to read English at a 6 INTERVENTION grade level; and (3) possess in-home internet connection. Study candidates were excluded if medical contraindications (e.g., seizure disorders) prevented them from playing video MYSTIC ISLE GAME games. Table 1 depicts the participants’ demographic and clinical characteristics. The Mystic Isle software (Lange et al., 2012) runs on a standard desktop or laptop PC. The Microsoft Kinect® International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu camera connects to the computer via USB and serves as components are designed to be easy to assemble and the input sensor that detects and tracks a player’s joint navigate. movements in 3D space (Figure 1). The software and Figure 1. Mystic Isle game set-up in a participant's home. The participant is seated and reaching forward with his right arm. Visible are the monitor, the Kinect sensor, the laptop, and the wireless mouse. Designed for use by an occupational therapist (OT), the generated five treatment goals. The OT subsequently software contains a control panel through which the game customized the game and calibrations in accord with the can be calibrated and modified based on the player’s assessment findings (Table 2). For example, Participant 2 physical rehabilitation and exercise treatment plan needs identified a goal of being able to kneel and reach forward to and goals. For example, it allows for tailoring of parameters clean her bathtub. In the custom calibration, participant 2 such as game timing (for rapid game start), physical tasks, kneeled on the ground and reached forward for virtual visual preferences, repetition number, and challenge level. objects during game interaction. This challenged and helped One additional feature is that the preferences and restore the specific abilities necessary to complete the calibrations can be updated as needed throughout the functional task of cleaning the bathtub: trunk control, core course of the intervention. strength, and reaching. Each week the OT reviewed the adequacy of the game settings and calibrations in relation to automated progress report findings. When needed, she GAME SELECTION AND CALIBRATION made changes to game settings and calibrations based on her clinical judgment and on participant progress by An OT administered the Canadian Occupational remotely logging-in to the participant’s home-based Performance Measure (COPM) (Law, 1998) to identify each computer. participant’s occupational performance problems and International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu Table 2. Canadian Occupational Performance Measure (COPM) Goals and Associated Game Sessions for Each Participant Participant COPM Goal Game Session Exercises 1 Walk on uneven ground 1. Step up onto platform 2. Reach with right arm 3. Reach with both arms + leg extension exercises Fold laundry 1. Reach with left arm 2. Reach with both arms while standing and then sitting Fasten zippers 1. Reach with left arm while standing Find items in a crowded 1. Play memory games during sitting and standing tasks environment Read faster 1. Perform matching games while sitting and standing tasks 2 Chop food 1. Reach with right arm Kneel to clean bathtub 1. Reach with left arm in tall kneeling 2. Squat 3. Sit-to-stand Use railing while going 1. Step forward up/down stairs 2. Reach in standing position Remember names 1. Play Memory games while stepping forward Put hair in a ponytail 1. High reach with right arm 3 Reading 1. Remember words 2. Choose antonym See items on left side of 1. Dual-task game visual field 2. Sort objects Communicate with others 1. Recall words Manage money during 1. Add two numbers transactions 2. Match numbers 3. Remember numbers Maintain focus for extended 1. Dual-task game for extended period of time (session duration > periods of time 10 minutes) 4 Fold clothes 1. Reach with left and right arm in standing Walk for longer periods of 1. Reach both arms in standing for extended period of time time (session duration > 5 minutes) Reaching with both arms while standing on compliant surface Walk on sand at beach 1. Reach alternately with left and right arms while standing on compliant surface Stabilize items using 1. Reach with left arm impaired side Button pants 1. Reach with left arm International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu CLINICAL IMPACT (SECONDARY IN-HOME SETUP OUTCOMES) Two researchers and the OT visited each participant’s Upper extremity function, perceived activity home to assist in setting up the Mystic Isle software, performance, balance confidence, and quality of life were monitors, Microsoft Kinect® sensor, and computer assessed at baseline, as well as 2 weeks later (i.e., just prior peripherals. The in-home setup location was determined in to intervention commencement, and following intervention). cooperation with each participant and, if necessary, his/her Upper extremity function was assessed with the Fugl-Meyer family members/caregivers. The location was required to: Upper Extremity Assessment (Fugl-Meyer, Jassko, Leyman, (1) provide adequate space for game equipment and Olsson, & Stenlind, 1975). This performance-based movement and (2) allow for Internet connectivity or wireless assessment is well validated and reliable for the chronic Internet access. In addition to instructing participants in how stroke population (Duncan, Propst, & Nelson, 1983; Hsieh et to set up the technology, researchers also taught them how al., 2009). Perceived activity performance was assessed to troubleshoot technical issues, navigate the gaming menu, with the Canadian Occupational Performance Measure and load intervention tasks. (COPM) (Law, 1998). Structured as an interview and self- rating of performance and satisfaction with performance, the COPM has high validity and reliability for persons with INTERVENTION DURATION chronic stroke (Cup, Scholte op Reimer, Thijssen, & van Kuyk-Minis, 2003). Balance confidence was assessed Each participant was instructed to achieve at least 4 through a self-report measure, the Activities-Specific hours of game play per week over the 6-week intervention Balance Confidence Scale (Botner, Miller, & Eng, 2005). An period. The duration of each game play session was left to additional self-report measure, the Stroke-Specific Quality of the participant’s discretion. For this reason, game play Life Scale (Williams, Weinberger, Harris, Clark, & Biller, session duration varied among participants. None of the 1999), was utilized to assess stroke-related quality of life. study participants were receiving therapy outside of this Both the Activities-specific Balance Confidence Scale and study. the Stroke-Specific Quality of Life Scale have good validity and reliability for the chronic stroke population (Botner, Miller, & Eng, 2005; Lin et al., 2010). OUTCOMES STATISTICAL ANALYSIS FEASIBILITY AND USABILITY OF THE The results of the Game Experience Questionnaire and MYSTIC ISLE GAME (PRIMARY OUTCOMES) System Usability Scale were expressed as a distribution of Likert scale responses for each participant. The semi- The primary outcomes of this study were the usability structured interview data were analyzed using a grounded and feasibility of the Mystic Isle in-home exercise program theory approach (Corbin & Strauss, 2008). Two independent for persons with chronic stroke. These outcomes were researchers coded the data to detect emerging themes. assessed at post-intervention only using an embedded They also met frequently for inter-coder agreement checks. design, mixed-methods approach (Creswell, Klassen, Plano The quantitative data were then synthesized with the Clark, & Smith, 2011). Feasibility and usability were qualitative data to substantiate emerging themes. For the quantitatively measured using the Game Experience clinical evaluation data, baseline and pre-intervention scores Questionnaire, derived from IBM measures of system for each measure were averaged to produce a pre- usability (Lewis, 1995), and the System Usability intervention score for each study participant. The differences Questionnaire (Bangor, Kortum, & Miller, 2009). Both in the participants’ post- and pre-intervention scores were instruments utilize a 5-point Likert scale rating. Qualitative compared to the Minimal Detectable Change (MDC) score assessment of feasibility and usability was determined via a for each clinical assessment tool. The MDC was used for semi-structured interview that focused on the following: (1) this study because it provides a criterion for the smallest the attractiveness and appeal of the Mystic Isle intervention; amount of change in an outcome measure that corresponds (2) system integration, including technology set-up, into the to perceptible change in ability or functional status. home; and (3) the rehabilitative potential of Mystic Isle. Additionally, the Mystic Isle software provided data on the exact number of minutes each participant spent playing the game each day. International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu Participant 2 averaged 3.5 hours/week, whereas Participant RESULTS 3 only averaged 1 hour/week. All participants found it difficult to follow the 4-hour recommended length of game- playing each week due to busy schedules or previous commitments. For example, all participants were regularly PARTICIPANT EXPERIENCE AND engaged in activities in and outside of the home such as SYSTEM USABILITY yoga, book club, and stroke support groups. In the words of one participant: “I was just trying to figure out when to get it Three out of four participants rated the system as in because I am so busy.” Additionally, participants reported “usable” or “very usable.” This was evidenced by their that they were often fatigued or stressed after a full day of average ratings of 1.46, 2.19, and 2.76 on the Game activity: “I just feel so overwhelmed sometimes, [with] all the Experience Questionnaire and System Usability Scale, things I got to do.” To overcome this barrier, some of the where 1 = very usable, and 5 = not usable at all. Participant participants attempted to play in the morning before going 3 had an average rating of 4.42 due to reported difficulty out or divided the time invested into multiple short durations understanding the directions to start the game on the laptop. throughout the day. Seventy-five percent of game play Despite the therapist and study team’s best efforts to include sessions across participants occurred exclusively in the visual cues and reminders, Participant 3 experienced afternoon or evening. frustration loading the game and navigating through the three steps required to begin playing. Moreover, Participant For Participant 3, accessing the game on the computer 3 also continued to attempt playing the game without a (e.g., finding the icon to click, following the steps to log-in) caregiver present to load it or to troubleshoot, even though presented a barrier to play. Participant 3 was able to play the therapist and study team recommended she include a the game with verbal cues when the OT was present in the caregiver in the process. Participant 4 experienced minor home; however at other times, she did not use assistance technical issues but was able to resolve them during a from caregivers to load or play the game. Due to her phone call to the treating therapist or study team. Once the cognitive deficits, she had difficulty processing and following intervention was completed, participants identified factors directions, both written and pictorial. However, none of the that facilitated the use of Mystic Isle as an in-home participants mentioned the physical environment or physical intervention, identified barriers, and made suggestions for technology set-up as a barrier to use. future software improvements. SUGGESTIONS FOR FUTURE USE FACTORS THAT FACILITATED USE Participants provided the following feedback on how to Participants indicated they liked the customized aspect improve the Mystic Isle intervention: (1) Increasing the of the Mystic Isle. They claimed they were inspired to play amount of choice on the part of the player; (2) Including and enjoyed the games because they were tailored to help background music; (3) Providing more on-screen them achieve their particular goals. As one participant performance feedback; (4) Maintaining the on-screen stated, “It was fun when I could tailor a game to me.” The instructions, but allowing the player to progress in the game overall desire to improve and “get [their] bod[ies] and without having to read them; and (5) Adding an on-screen mind[s] better” was the main incentive for all participants. “Help” link for technical issues and troubleshooting. Further, they indicated that they appreciated having a variety of games to help them reach their goals and multiple means to improvement: “I enjoyed that they [Mystic Isle games] were [each] different.” Furthermore, the three CLINICAL EVALUATION participants without cognitive difficulties were additionally Participants 2 and 4 reported an increased ability in the motivated by the motor + cognitive challenge games. self-care domain on the Stroke-Specific Quality of Life scale (post- and pre-intervention differences of 4.0 and 9.0, respectively), which was greater than the MDC of 4.0. Participant 2 obtained an increased score in COPM BARRIERS satisfaction (a post- and pre-intervention difference of 2.4), Time management was the main barrier identified by which was greater than the MDC of 1.75. No scores on participants. On average, participants played 30 minutes per other clinical evaluation measures were greater than the day, 5 days per week; totaling 2.5 hours each week. MDC for each respective measure (Table 3). International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu Table 3. Results of Clinical Outcome Measures for Each Participant at Three Time Points Clinical Outcome Measure Baseline Pre Post 1 2 3 4 1 2 3 4 1 2 3 4 Fugl-Meyer Assessment- Upper Extremity (x/66) 24 45 66 25 24 44 66 28 24 42 66 33 Canadian Occupational Performance Measure Performance (x/10) 3.6 2.4 3.4 1.4 3.4 2.6 3.4 1.2 4.2 3.6 1.2 2 Satisfaction (x/10) 1 2 1.8 1 2.2 1.8 1.4 1 2.4 2.8 4 2.2 Activities-specific Balance Confidence Scale (%) 59.38 75.31 88.75 59.69 70.63 74.25 81.25 65.63 71.88 78.75 94.38 54.38 Stroke-specific Quality of Life Scale Energy (x/15) 7 15 6 13 6 15 11 14 8 15 15 11 Family Roles (x/15) 9 12 5 11 13 12 8 10 12 15 9 11 Language (x/25) 20 25 5 25 24 25 10 23 6 25 15 25 Mobility (x/30) 25 30 29 27 14 30 28 20 18 30 30 23 Mood (x/25) 13 24 13 24 20 23 9 21 22 25 16 21 Personality (x/15) 5 12 6 12 7 9 6 13 6 13 7 10 Self-Care (x/25) 12 24 23 24.5 14 24 19 21 22 22 25 21 Social Roles (x/25) 17 16 5 18 8 10 10 12 10 20 17 15 Thinking (x/15) 8 15 3 9 6 15 6 9 8 15 3 10 Upper Extremity Function (x/25) 12 23 20 13 14 20 20 9 14 24 21 11 Vision (x/15) 13 15 13 15 12 15 11 15 14 15 13 15 Work/Productivity (x/15) 14 8 9 8 8 13 9 9 6 9 9 10 Total (x/245) 155 219 137 199.5 146 211 147 176 146 228 180 183 International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2015.6177) International Journal of Telerehabilitation • telerehab.pitt.edu older, we found that Mystic Isle was described as lacking sufficient user-friendliness. The older adults in that study indicated they would be more likely to adopt the game- based intervention if the system was simpler, more intuitive, DISCUSSION and had an easy “push-button-start” (Proffitt & Lange, 2013). The primary purpose of this study was to explore the Currently, our investigative team is modifying the Mystic Isle feasibility and utility of a 6-week, game-based, in-home game based on this feedback. exercise program for persons with chronic stroke. Three of Although cognitive deficits and technological concerns the four participants were able to successfully use the impeded use in this study, the primary reason all study Mystic Isle intervention as evidenced by their ratings on participants did not achieve the 4-hour per week intervention usability scales and their subjective responses to open- goal was due to the additional activities in which they were ended interview questions. However, the hours invested by engaged. As stated earlier, participants claimed that they all participants fell short of the recommended time. could not devote sufficient time to the exercise program Participant 2 consistently completed the intervention for the because they were either too busy or simply overwhelmed most amount of time per week (3.5 hours/week for all 6 with all of the things they had to do. Some evidence weeks). She also experienced improvements in clinical suggests that, even though many persons with chronic evaluation measures outside of the MDC, but these stroke report returning to many of their pre-stroke activities, improvements were subjectively self-reported. Although the amount of time and effort required to complete these Participant 2 had higher baseline levels of function, the two activities often increases, even dramatically, in comparison participants with greater deficits in motor and ADL function to pre-stroke levels (Mayo, Wood-Dauphinee, Cote, Durcan, were still able to use the Mystic Isle game in their home. The & Carlton, 2002). For many stroke survivors, the motivation majority of recent studies investigating interventions for the to complete exercises and therapeutic interventions is chronic stroke population target persons much like strong, but having sufficient time to do so can be Participant 2 who have higher levels of motor function (i.e., problematic (Proffitt & Lange, 2013). Consequently, tailoring some hand movement and a score greater than 45 on the game sessions and exercises so that they can be completed Fugl-Meyer Assessment-Upper Extremity) (Combs, Kelly, with minimal effort and in short amounts of time is likely to Barton, Ivaska, & Nowak, 2010; Egan, Kessler, Laporte, facilitate adoption on an ongoing basis by stroke survivors. Metcalfe, & Carter, 2007; Pang, Eng, Dawson, McKay, & Harris, 2005). The results of this study suggest that it may Many studies have revealed that adherence in self- be feasible to implement an in-home intervention with stroke directed programs tends to be poor (Chen, Neufeld, Feely, & survivors with lower levels of motor and daily function. Skinner, 1999; Forkan et al., 2006; Jurkiewicz, Marzolini, & Oh, 2011). The studies by Forkan and colleagues (2006) Even with lower levels of motor and daily functioning, and Chen and colleagues (1999) utilized a common method the participants were able to use the in-home technological of tracking home exercise program adherence: an exercise intervention; however, poorer cognitive ability impeded log or report completed by the patient. Jurkiewicz and game engagement. As mentioned above, despite the OT’s colleagues (2011) did not report specific methods for efforts to remotely troubleshoot and provide reminders, tracking adherence; however they provided suggestions to cognitive deficits were found to be a significant barrier to increase adherence including increasing support from family Participant 3’s engagement in the game. It is unclear members and physicians. Suggestions provided by Chen whether ongoing caregiver support would have lessened or and colleagues (1999) included a link to the health belief even eliminated this problem. This finding suggests that as it model by suggesting that therapists ensure that patients feel stands, the Mystic Isle game may be most appropriate for confident in their abilities to complete the prescribed individuals who possess minimal cognitive deficits. In a exercises. This is linked to one of the central tenets of Self- future study, it may be helpful to determine minimum cut-off Determination Theory that underlies Mystic Isle: scores on the Mini Mental State Examination that are competence. Additionally, Forkan and colleagues (2006) predictive of successful adoption of the intervention. reported that the largest barrier to adherence in their study Even in the absence of cognitive deficits, the was change in health status, and the authors recommended technology itself in some instances proved difficult to use. return visits to the clinic to update the program. The For example, Participant 4, who suffered no cognitive advantage of using Microsoft Kinect® sensor technology in deficits, had issues starting and playing Mystic Isle including the home is that the OT (or any other care provider) can logging into the game and selecting the appropriate game remotely check progress and update the program without tasks. Consequently, he had to intermittently stop playing requiring the patient to spend precious time in travel to the the game to seek help from the study team, inadvertently clinic. Further, Mystic Isle provides an objective measure of impacting the frequency of use and revealing limitations of the amount of time a user plays a game, the number of using Mystic Isle as a self-directed intervention. Similarly, in repetitions a player achieves, along with other valid one of our recent studies involving older adults aged 65 or kinematic data (Fern’ndez-Baena, Susin, & Lligadas, 2012) International Journal of Telerehabilitation • Vol. 7, No. 2 Fall 2015 • (10.5195/ijt.2014.6177) International Journal of Telerehabilitation • telerehab.pitt.edu on performance. Not only are such reports helpful for Isle in improving motor function or performance of ADLs, treating therapists, they also create an incentive for persons larger trials must be conducted. with stroke to adhere to a program and improve on performance. In this regard, participants indicated that the combination of the customized nature of the games, the relationship of the exercises to self-identified goals, and the REFERENCES objective technologically-provided feedback were key to motivating them to stick to the program. Adamovich, S. V., Merians, A. S., Boian, R., Lewis, J. A., Tremaine, M., Burdea, G. S., ... & Poizner, H. 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International Journal of Telerehabilitation – Pubmed Central

Published: Nov 20, 2015

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