Virtual reality games for rehabilitation of people with stroke: perspectives from the users

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  • RESEARCH PAPER

    Virtual reality games for rehabilitation of people with stroke:perspectives from the users

    GWYN N. LEWIS, CLAIRE WOODS, JULIET A. ROSIE & KATHRYN M. MCPHERSON

    Health and Rehabilitation Research Institute, AUT University, Auckland, New Zealand

    Accepted March 2011

    AbstractPurpose. The purpose of this study is to evaluate the feasibility and users perspectives of a novel virtual reality (VR) game-based rehabilitation intervention for people with stroke.Method. Six people with upper limb hemiplegia participated in a 6-week intervention that involved VR games. A series ofeight progressively complex games was developed that required participants to navigate a submarine in a virtual oceanenvironment. Movement of the submarine was directed by forces applied to an arm interface by the affected limb. Outcomemeasures included assessments of arm function, questionnaires evaluating the intervention and a semi-structured interviewconcerning the participants opinion of the intervention.Results. All participants improved their performance on the games, although there were limited changes in clinical measuresof arm function. All participants reported that they enjoyed the intervention with a wide range of overall perceptions of theexperience of using VR. Three themes emerging from the interview data were: stretching myself, purpose and expectations ofthe intervention and future improvements.Conclusions. Participants found that taking part in this pilot study was enjoyable and challenging. Participants feedbacksuggested that the games may be motivating and engaging for future users and have provided a basis for further developmentof the intervention.

    Keywords: Hemiplegia, upper limb, rehabilitation, virtual reality

    Introduction

    Spontaneous recovery of movement function follow-

    ing a stroke normally completes by 6 months [1].

    However, further improvements in movement ability

    have been demonstrated even in chronic stroke

    following the application of rehabilitation interven-

    tions [24]. Despite this continued potential for

    recovery, patients motivation and adherence to

    treatment protocols are major barriers to recovery

    [5]. In a survey by Page et al. [6], it was found that

    almost 70% of stroke survivors were unlikely to

    participate in a specific treatment protocol even

    when it was proven to be effective. The major

    concerns expressed by patients and therapists were

    scheduling time, safety and availability of appropriate

    resources. The development of safe rehabilitation

    interventions that target motivation is likely to

    enhance patients time dedicated to treatment

    protocols and consequently facilitate the recovery

    of movement function.

    Virtual reality (VR) games aim to create fun

    environments that engage users and increase their

    motivation and have been used in a range of

    contexts, including rehabilitation [710]. The appli-

    cation of VR in movement rehabilitation affords a

    number of benefits over standard treatment options.

    VR provides a controlled environment in which users

    can acquire confidence in performing tasks that may

    otherwise compromise safety. Virtual environments

    can easily be adapted to the needs of the individual to

    provide a more target-oriented rehabilitation that

    focuses on the specific requirements of the user [11].

    The ability to provide controlled or augmented

    feedback is a further advantage of VR systems.

    Provision of feedback is critical for learning and

    rehabilitation [12,13], and visual or auditory feed-

    back can easily be manipulated in VR environments

    Correspondence: Dr. Gwyn Lewis, Health and Rehabilitation Research Institute, AUT University, Private Bag 92006, Auckland 1142, New Zealand.

    Tel: 64-9-921-9999. E-mail: gwyn.lewis@aut.ac.nz

    Disability and Rehabilitation: Assistive Technology, September 2011; 6(5): 453463

    ISSN 1748-3107 print/ISSN 1748-3115 online 2011 Informa UK, Ltd.DOI: 10.3109/17483107.2011.574310

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  • to facilitate the learning experience [14]. Finally,

    repetition is a key ingredient in almost all areas of

    motor rehabilitation [15,16]; therefore, the capacity

    to provide an ever-changing environment that con-

    tinues to train the same underlying deficit is a major

    advantage over real-world situations.

    Several studies have assessed the use of VR

    technologies in people with chronic movement

    impairments following stroke. These have adopted

    a variety of custom-designed and commercially

    available systems incorporating head-mounted de-

    vices [10,17], large-scale video projections [18,19]

    and desktop computer or television displays [2025].

    Almost all of these studies have reported improve-

    ments in movement ability following VR training,

    both in terms of improved performance on VR

    training tasks [7,2527] and improvements in more

    standardised clinical rating scales [9,20,22,26].

    However, there is a lack of in-depth and structured

    information on the users perspectives of these VR

    interventions. Such information could be used for

    future development of systems that more specifically

    meet the needs of the end users or indicate

    populations that respond more positively to VR-

    based rehabilitation.

    The aims of the current feasibility study were

    three-fold. First, we wanted to design a VR-based

    intervention to improve the upper limb movement in

    people with stroke. Up to 60% of people with chronic

    stroke are reported to have a residual deficit of arm

    function [28,29]. We aimed to develop a series of

    VR games that incorporated motor learning princi-

    ples of progression, feedback and goal attainment

    that encouraged independent control of upper limb

    joints. The second aim was to determine the effects

    of the developed intervention on arm function. The

    final aim was to determine the users perspectives of

    the intervention. This included how the intervention

    influenced their arm function, the usability of the

    system, enjoyment levels and any alterations that

    would make the system more appealing.

    Methods

    A prospective feasibility study with both quantitative

    and qualitative data was conducted. The study

    involved a small sample to develop the game with

    feedback from participants, identify the potential

    impact and acceptability and inform future sample

    size.

    Participants

    Six people with hemiparesis, following a single,

    monohemispheric stroke, participated in the study

    (see Table I for details). Participants were required

    to be at least 6-months post-stroke, have a residual

    deficit in upper limb function, have normal or

    corrected-to-normal hearing and vision and have

    no cognitive or perceptual deficits that impaired their

    ability to interact with a virtual environment or might

    increase their susceptibility to cybersickness. Tar-

    geted sampling of individuals was used to include

    people with a range of ability levels and experience

    with computers. Ethical approval for the study

    was received from the local Ethics Committee, and

    informed written consent was obtained prior to

    participation.

    Set-up

    Participants were seated in front of a computer

    monitor with their impaired arm positioned at 458shoulder abduction, elbow at 908 and the forearmfully pronated (Figure 1). The forearm and wrist

    were secured in a padded fibreglass cast. The cast

    was mounted on a six degree-of-freedom load cell

    (67M50A, JR3 Inc, USA) and bolted to a height

    adjustable table. Application of forces and torques

    to the load cell controlled the movement of a

    submarine shown on the computer monitor, such

    that the submarine moved or rotated in the same

    direction as the forces and torques applied by the

    forearm.

    VR games

    The VR intervention consisted of a series of eight

    games in which the submarine was manoeuvred

    through an ocean environment. Three of the games

    required users to move the submarine in single

    planes of movement up and down, forward and

    backward or side to side to randomly selected

    targets. Users scored points for each target they

    reached within a 3-min game. The difficulty of these

    games was progressed by increasing the sensitivity to

    Table I. Participants characteristics.

    ID Age Gender

    Years

    post-stroke

    Affected

    side DASH

    S1 55 M 9.5 R 48

    S2 60 M 6.9 L 18

    S3 75 F 2.0 L 30

    S4 69 M 1.4 L 47

    S5 71 M 1.4 R 53

    S6 69 M 1.4 R 58

    DASH, disabilities of the arm, shoulder and hand (maximum

    100); M, male; F, female; R, right; L, left.

    454 G. N. Lewis et al.

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  • forces in the target plane, and then by increasing the

    planes of movement in whic

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