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 [2–4]. 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 [7–10]. 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: þ64-9-921-9999. E-mail: gwyn.lewis@aut.ac.nz

Disability and Rehabilitation: Assistive Technology, September 2011; 6(5): 453–463

ISSN 1748-3107 print/ISSN 1748-3115 online ª 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 [20–25].

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 [7,25–27] 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 forearm

fully 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 which the participants could

move the submarine. The remaining five games

required the users to move the submarine in multiple

planes of movement. Users accumulated points by

moving the submarine to different targets or were

timed in their completion of a set course. These

games were again progressed by increasing the

sensitivity to forces in specific planes. In this way,

participants progressed through several levels of

difficulty and received feedback in the form of scores

or times at each of these levels.

Intervention protocol

Each participant was asked to attend three 1-hour

sessions per week for a 6-week period. During that

time, the participants were individually progressed

through the games with the difficulty of each game

being increased based on their performance. Three

to four games were selected to be played in each

session. Participants were given graphical feedback of

their progress in each game after 3 and 6 weeks of the

intervention.

Outcome measures

The feasibility of the VR games as a rehabilitation

intervention was assessed by the participants’ atten-

dance at the intervention sessions, performance

(scores/times) in the individual games and progres-

sion through the series of increasingly more difficult

games. Arm function was assessed using the

Fugl-Meyer Assessment [30] and the Box and Block

Test [31].

Participants’ perspectives of the intervention were

assessed using a post-intervention questionnaire and

an interview. The post-intervention questionnaire

was adapted from Merians et al. [9], who assessed

the use of a VR intervention to improve hand

function in people with stroke. Although the

reliability and validity of the post-intervention ques-

tionnaire have not been established, the questions

were selected and modified from a validated and

reliable questionnaire used by industry usability

laboratories to evaluate user interfaces [32]. Minor

modifications to the measure for our study involved

the inclusion of terminology relating to the ‘sub-

marine game’ and were made to ensure the questions

were specific to the intervention being evaluated.

Each participant was also interviewed by an

independent researcher after completion of the

intervention. Interviews were semi-structured, with

the researcher asking open-ended questions around

topics including: what aspects, if any, of the

programme that were liked or disliked; comfort

during and after the sessions; comparison with other

upper limb rehabilitation; willingness for future

participation and any suggested improvements.

Participants’ perceptions of change in arm move-

ment and function during and outside session times

were also canvassed. The independent researcher

conducted all interviews, each taking 30–45 min to

complete. All interviews were recorded, subse-

quently transcribed verbatim and rechecked for

accuracy following transcription against the audio

file. In keeping with qualitative descriptive methods

[33], content analysis was applied [34]. Transcripts

were coded line by line into codes, and these codes

were grouped into categories of similar items. NVivo

8 software (QSR International, Australia) was used

to store the data, record coding and any memos

associated with the interviews. Categories identified

were compared between participants and were

checked back against the data looking for statements

that qualified, expanded, countered or supported

them. In this way, themes that provided an explana-

tion of participants’ experiences emerged from the

data. Validation of the results was enhanced by

rigorous checking back of emerging themes against

the data, peer review of the results and member

checking.

Figure 1. Set-up for the VR games. (A) The participants inserted

their arms into the interface. (B) Forces detected by the load cell

(incorporated into the interface) controlled the movement of a

submarine through virtual environments displayed on a computer

monitor.

Perspectives on virtual reality games for stroke 455

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Results

Feasibility

All six participants attended all 18 sessions over the

6-week intervention period. The five most basic

games were able to be completed by all participants.

Three of the participants attempted all of the

available games; however, the remaining participants

were unable to control the submarine in the multiple

planes required to complete the more complex

games. In all games attempted, each participant

demonstrated improvements in performance over

time with regard to times or scores. As each

participant’s programme was progressed individually

by introducing more complex games and modifying

the difficulty within each game, statistically mean-

ingful descriptions of improvements over time

cannot be made as progressions in difficulty routi-

nely resulted in a subsequent decrement in scores or

times. Example charts of performance for one

participant are shown in Figure 2. This participant

clearly shows progressive improvements in the games

over time that are modulated by increasing the

difficulty of the games.

Arm function

Table II shows the pre- and post-intervention Fugl-

Meyer Assessment and Box and Block scores for

each participant. One participant (S5) improved by

five points on the Fugl-Meyer Assessment, but there

were no other clinically significant changes in arm

function in any individuals.

Participants’ perspectives

Results from the post-intervention questionnaire

indicated that most of the participants enjoyed the

intervention, believed that their arm function im-

proved during the treatment period and rated

the control and usability of the games as high.

Individual responses for each question are shown in

Table III.

Three themes emerged from the interview data

that appeared to capture the breadth of participants’

experiences. These were: ‘stretching myself’, ‘pur-

pose and expectations’ and ‘future improvements’.

Each theme with contributing categories is described

in turn. How these results relate to current literature

on experiences of people using new technologies

following stroke is canvassed in the subsequent

discussion. Quotes in support of the analysis have

been anonymised by use of random alphabetical

identifiers and gender neutral language in order to

prevent identification of individuals in this small

group of participants.

Stretching myself. The VR games were acceptable to

all participants, with positive responses to being

asked whether they liked being involved; words such

as ‘fun’, ‘interesting’ and ‘enjoyed’ were regularly

used in participants’ descriptions. The reasons as to

Figure 2. Scores/times from an individual participant (S1) in four

of the VR games. Each point represents one completion of the

game; if selected to be played, each game was played two to four

times per session. The hollow circles indicate that the difficulty

of the game was increased at that point. The graphs show

progressive improvements in performance for each game and that

increasing the difficulty of the game temporarily reduced the

performance.

456 G. N. Lewis et al.

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why involvement in the study was enjoyable centred

on participants’ perception of stretching themselves

by taking part. This theme of ‘stretching myself’ was

made up of three categories: novel activity, challen-

ging current ability and getting out and about.

Participants spoke of the enjoyment and challenge

associated with taking part in something novel:

I enjoyed it . . . because it was so novel for me, because

I don’t play computer games. (Participant D)

For some, the novelty of the activity rather than the

form of game was what appealed. However, the

novelty of the intervention was not seen as positive by

everyone. For one participant having to do yet

another new thing as part of their rehabilitation was

a potential barrier to getting involved:

I didn’t really want to do it, I thought it would be too

hard; it’s just getting here and all that sort of stuff . . .

I think anything, new experiences, you’ve got a whole lot

of things you’ve got to learn unfortunately, when you

[have a stroke] so this is just one bit of it I suppose.

(Participant F)

This potential barrier did not prevent the partici-

pant from taking part, or completing all sessions, or

from expressing an interest in taking part in VR

programmes in the future if these were offered.

The VR games challenged what participants were

currently doing outside of the intervention sessions

and what they perceived they were able to do with

their more affected hand. Part of the challenge for

some participants was developing strategies to

succeed during the games. Participants reflected on

performance during the games, and whether they

perceived they were using their more affected arm

differently outside of the experimental setting.

A number of participants reflected on enjoying the

challenge of taking part:

I think I enjoyed the challenge of it. Something I

wouldn’t have done (Participant F)

It showed me that I can take control of the engine

without me having the full use of my hand (Participant C)

Challenging current ability was not only limited to

the physical use of the arm but also to the cognitive

demands of the tasks:

I was concentrating you know. Which I think was good

for me. Because some days with a stroke you know, my

mind wanders. (Participant B)

Table II. Arm function measurements pre- and post-intervention.

Fugl-Meyer

Score*

Box and

Blocks (A)

Box and

Blocks (NA)

Subject Pre Post Pre Post Pre Post

S1 46 48 – – – –

S2 58 56 39 39 59 63

S3 60 60 40 32 48 42

S4 58 57 24 28 57 58

S5 49 54 25 26 63 61

S6 23 25 0 0 70 75

Mean

(SD)

49 (14) 50 (13) 26 (16) 25 (15) 59 (8) 60 (12)

A, affected arm; NA, non-affected arm; –, not collected; SD,

standard deviation.

*Fugl-Meyer Score is out of a maximum of 66.

Table III. Post-intervention questionnaire responses.

Statement S1 S2 S3 S4 S5 S6 Mean

This study improved my arm movement 5 4 7 1 4 6 4.5

With more practice in the submarine game, I feel that my arm

might improve more

7 6 7 1 5 6 5.3

I would be very willing to continue the study for another 2 weeks 7 7 7 1 5 6 5.5

I would be very willing to play the submarine game at home if it was available 7 7 2 2 5 6 4.8

I found the submarine game to be engaging 7 7 4 2 6 6 5.3

It would be fun to do this game on the internet with other people

who have had a stroke

5 7 1 2 5 4 4.0

I wish that the submarine game had been part of my original therapy 7 7 3 2 5 3 4.5

The submarine game took too long 6 7 5 4 5 7 5.7

The strength measures were more interesting than the submarine game 3 3 7 NA 4 4 4.2

The submarine game was enjoyable 7 7 1 3 5 6 4.8

The ocean environment made the game more interesting 4 5 7 2 5 5 4.7

The submarine game was easy to understand 7 7 7 5 5 7 6.3

It was fun to move the submarine around 7 6 7 4 5 6 5.8

It was hard to tell how well I was doing in the game 7 7 2 6 5 2 4.8

I would prefer to do real-world tasks rather than the submarine game 1 1 2 6 5 4 3.2

I would like to compete against others of equal skill when playing the game 2 7 1 6 5 5 4.3

NA, not answered.

1 ¼ strongly disagree; 7 ¼ strongly agree with statement.

Perspectives on virtual reality games for stroke 457

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Some participants reported increased tiredness

due to the concentration required to take part in the

VR study. Two participants attributed sleeping

better at night to the cognitive effort the participa-

tion required; however, no participant reported that

they had to alter usual activities as a result of

fatigue.

All participants described improvements made in

performance in some, if not all, of the games

attempted and were very positive about these

improvements:

I got better as time went on, I got better at them

all . . . and I think it was practice only that made you get

better, because I’m not brilliant on a computer, so yeah I

think it was only practice. (Participant A)

Y’know I sort of realised that after a while that um I was

developing the four movement skills. And finally

finished up with um . . . the challenge of using all the,

all the movements in one game. (Participant F)

Based on the changes seen in performance, most

participants set themselves targets as to what they

wanted to achieve in each game:

I always try to beat my last record, and that is

improvement, and if I do not succeed, at least I give it

a try and without bumping into things. Sometimes, like

one day I was very hot [laughs] I beat all the scores!

(Participant C)

In order to achieve their targets, participants

developed their own strategies about how to play

the game. For some participants, this involved

occasionally concentrating on different aspects of

the game, for others, it involved altering their

shoulder or body position when manipulating the

controller. One participant developed a ‘game within

the game’:

When you start the game if you don’t do properly you

hear a lot of beeps . . . I done it the first time without

sound then I play it with the sound, and you try and hit it

less you know, sideways and so on and if you hit it less

that means you’re perfectly moving. But it depends on

whether you are wanting to achieve the game as silent or

the points. Sometimes I bash [the sides] but I try to get

the most points. (Participant C)

While all participants described the challenge of

taking part as a positive experience, participants’

dislikes about the VR game focussed on not being

able to achieve:

I couldn’t seem to get that diagonal going, you know.

And when she was saying lift your elbow, [the

researcher] was saying lift your elbow, I thought I had

lifted my elbow . . . and I had this urge to get my right

hand to come over and give it a lift. (Participant B)

I got frustrated, I couldn’t achieve, I’d like to go back

and have another go. Being a little bit competitive I

don’t like being beaten [laughs]. (Participant D)

Participants had mixed responses when asked

whether they felt there had been any changes in the

use of their more affected arm outside the game

during or following the 6-week study. Two partici-

pants were emphatic that there had been an

improvement in a particular movement or function

that they attributed to the games. It should be noted

that neither of these participants, while they im-

proved in VR game performance, improved func-

tionally according to the outcome measures used:

I noticed the other night, it’s always been hard for me to

turn the pot you know to strain the spuds and I sort of

lifted it off and put it over the sink and had done it

before I thought ‘‘oh God, I found that hard once’’, you

know. You see there’s little things I can do that I can’t

show all the time, but to myself I feel I’m doing them.

(Participant B)

I think there has, I get that amount [indicates a small

amount] of movement each week improvement and I

don’t know what it comes from: ordinary physio,

acupuncture or that, but I think that [the games] did

help the sideways movement. So I have to put it down to

the games. (Participant D)

Some participants thought there may have been

changes in function, but were less sure as to the

cause:

I’ve talked myself into, ‘yes it’s helped me, it’s helping

me’, it might just be a subliminal message I’ve given

myself, but getting there slowly. (Participant E)

Other participants perceived the benefit of parti-

cipating as reinforcing the possibility of progress,

even if they didn’t see a change over the course of the

study:

I didn’t play it enough [to make a difference] but any

movement of the muscles will be of benefit to me. Now

because at least they are exercised. So it is a bonus . . .

glad I rose to this challenge. But yeah I do everything

with my [less affected] hand, and my [more affected]

hand it just supports sometimes. (Participant C)

I should always try and use my arm but it sort of - do I

try new things? Well . . . I just think there is a gradual

improvement all the time, and this sort of thing

improves it a bit faster, but I’m not sure. (Participant F)

I’m trying to carry more shopping . . . I’m getting there

slowly. Hopefully it will trigger something up in my

head, and it will come back to the way it was, I doubt it

though. (Participant E)

458 G. N. Lewis et al.

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Enjoyment was not limited to the game itself. Two

participants spoke about their involvement in the

study stretching their social engagement, as taking

part required them to ‘get out and about’.

It sort of forces me to get out, and think of other things

I can do during the day. (Participant E)

Participant B echoed this sentiment:

I just enjoyed that I was getting out and about.

Participant B spoke of ‘getting out and about’

repeatedly as a reason for enjoying taking part. This

participant also commented his/her preference for

the study and similar programmes to take place in

winter when there was not so much else available for

people with stroke to do:

I enjoyed it and it got me out of the house. I was just

thinking the other day it’s been all in lovely weather but

in the winter sometimes I feel like a caged tiger here.

I think it would be better you know [in winter], a lot of

stroke people probably feel the same that they’re

hemmed in, in winter (Participant B)

Purpose and expectations. The second theme emer-

ging from the data was participants’ perspectives on

the purpose of the study and their expectations they

had around their involvement. This theme encom-

passed two categories of ‘what is it for?’ and

‘comparison with other upper limb rehabilitation’.

For the participants in this study, the potential of

benefit to them was vital to their enjoyment and

involvement. These participants did not express

interest in playing computer or VR games apart

from in the context of rehabilitation:

I learned some important lessons that you should never

say not, never again, because you can be surprised at the

effect it has got on you to use your wrong hand. Your

dead hand. You give it life . . . I learned at physio with

the stretches and so on I got better and it goes from

there. And you see yourself doing progress and then

you’re keen to explore more things. (Participant C)

I think it was good value, from my point of view I did it

as an extra physio thing. And I gained, I don’t play

computer games, I would never play it again, only to get

extra physio benefit. . . . Oh yeah it was good fun, I

enjoyed it. I was looking forward to it . . . and I loved

doing it. But I wouldn’t go and play a game just for the

hell of it. I’d play the game to get better. (Participant D)

The VR game set up required isometric action of

upper limb muscles to operate the controller.

However, three participants spoke of expecting some

improvements in their hand dexterity following their

involvement. One participant expected that the VR

game would address all impairments associated with

the more affected arm and ceased other rehabilitation

accordingly. This participant perceived function

outside of the games had deteriorated:

. . . at home I had exercises to do, which I did, and they

got worse and worse as the time went over the six weeks

of the course. While I got better on the computer, I got

worse at other things. . . Lack of practice. So it means

that you’ve got to continue to do all the things, not just

part of them . . . I thought myself that the computer study

would have .. er sort of taken over from the other games

that I was playing. (Participant A)

Participants’ expectations were also tempered by

their experiences with current or previous upper limb

rehabilitation. While all were willing to take part in

future VR programmes if these were offered,

participants with recent rehabilitation experience

voiced a preference for the VR game as an adjunct

to other therapy:

Now physiotherapy is the best way . . . most people are

now playing the games and if they have a stroke they’re

used to playing games and its something for them to

exercise themselves, but I would not put it as the only

solution, because physiotherapy is the best one, but the

games just put another stage. (Participant C)

Another participant described physiotherapy re-

habilitation as more physical exercise and the VR

games as more ‘mental and precise’. Accordingly, a

combination of both modalities was thought to be

beneficial. In comparison, one participant reflected

on VR more favourably than his/her experience with

physiotherapy in the early stages following his/her

stroke, with VR offering a possibility of something

challenging to do independently in an in-patient

rehabilitation setting:

Something like this would be ideal out at [Rehab

Centre] because in the afternoon I used to get very

bolshie. Umm because it was always take you down to

the gym and the physio they had there didn’t seem to

help, it wasn’t setting a challenge or anything. (Partici-

pant E)

Improvements. Participants were invited to make

suggestions regarding improvements to the VR

games. Areas for improvement included the scoring

systems, the virtual environment and the opportunity

for competition. Participants appreciated the flex-

ibility of the system, commenting on the ability to be

adjusted to both their level of performance and

physical needs. Categories contributing to improve-

ments were reducing distractions and increasing

involvement. Some participants commented on

Perspectives on virtual reality games for stroke 459

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unequal weighting of scoring between games being

disheartening:

It was the rewards, it wasn’t great enough . . . you only

got one or two points at the most, whereas with others

you got 5 or 10. (Participant A)

Going through the hoops I got high scores on them and

I think when you get from say 15 or something then

down to 3 you think ‘oh bugger, I’ve failed on that one’.

(Participant B)

The use of sound effects during the games

provoked a mixed response, with some participants

describing these as distracting, while others used

them as a guide to improve their performance. What

was appreciated, regardless of preference, was the

ability for the sound effects to be on or off depending

on individual preference.

Participants with prior experience with boating

discussed the graphics in one case being appropriate,

and in the other distracting. The participant who

found the graphics distracting commented particu-

larly about the motion of the propeller:

The propeller of the submarine kept going in the same

direction all the time, it didn’t matter whether you were

going ahead or astern. But if, once you change your

forward or reversed direction it would have been handy

for the propeller to spin the other way to give more

realism to it . . . it didn’t change when you picked up

your speed it still turned slowly, so you lost that reality

there. Nah but apart from that minor distraction it was

good, I enjoyed it. (Participant E)

Two participants thought that having an environ-

ment that was less familiar was preferable to a more

familiar one, such as driving a car, as there would be

less expectation of the VR environment responding

as in real life, and therefore, any discrepancies from

reality would be less distracting.

Early discussions with the first participant in the

pilot study resulted in the scoring icons moved to be

more visible during play. Being able to see and

understand the scoring icons clearly for real-time

feedback of progress and performance was expressed

as important by a number of participants. Partici-

pants also discussed options around competition.

While competing with themselves was the main

objective for most, others also liked the idea of

being able to compete with other players’ scores to

provide a target to achieve. One participant sum-

marised a number of other perspectives on a means

of incorporating competition against others:

Something like a video game parlour that says today’s

highest score or your highest score so far on this game.

So you could actually get your score higher or your time

lower. (Participant C)

All participants found the underwater scenario

acceptable; however, two commented on not being

particularly aware of the environment. One partici-

pant would have preferred a free moving hand-held

controller that would have enabled movement of

the whole arm and not required fixation to a table.

This participant had previously played and enjoyed

Nintendo Wii games and would have preferred ‘real’

sports environments similar to the Wii.

Discussion

Few studies investigating the feasibility of using VR

or other novel interventions for participants with

disability have sought to identify users’ individual

responses to the intervention. While authors often

assert that their intervention was acceptable or well-

received by participants, the data on which these

statements are based are seldom provided. In studies

where participants’ experiences have been canvassed

following an intervention, the scope of response is

often predetermined by the use of closed question-

naires or Likert Scales [35,36]. The level of engage-

ment and motivation in performing tasks is posited

as factor in determining the success of rehabilitation

interventions using VR [5,37,38]. Users’ experiences

during pilot studies are, therefore, important to assist

determining the acceptability of novel rehabilitation

strategies and to establish the feasibility of embarking

on larger and more costly controlled trials. In the

current study, the importance of participants’ ex-

periences was determined a priori, and the collection

of these experiences was incorporated in the study

design, with in-depth interviewing followed by

appropriate qualitative methodology to analyse the

resulting data.

It is apparent from the data that the participants

enjoyed taking part in this study and that all

participants expressed an interest in involvement in

future studies using similar VR programmes for

stroke rehabilitation. They enjoyed taking part for a

variety of reasons, some of which were not specific to

the intervention modality. While most participants

said they enjoyed the VR games, being involved in

the VR study also provided an opportunity to stretch

themselves physically, mentally and/or socially. For

some participants, challenging themselves during

the games and observing progress through levels of

difficulty and real-time score feedback meant en-

couragement to continue trying. As one participant

expressed it; ‘it showed me I am able to do

something with my arm, even if I can’t do every-

thing’. Some participants reported an increase in arm

function following their participation, although

the quantitative results show very limited changes

in the outcome measures used. The controller set-up

460 G. N. Lewis et al.

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constrained participants to isometric muscle activa-

tion; there would be clinical merit in using VR as an

adjunct to evidence-based, task-specific upper limb

rehabilitation, as from these participants’ responses,

combining these approaches is likely to be accepta-

ble, enjoyable and motivating. We also suggest that

future studies use outcome measures such as the

Motor Activity Log [39] in conjunction with

objective measures of real-world arm use (see, for

example, the Functional Arm Activity Behavioural

Observation System [40] currently under develop-

ment) that are more likely to capture any improve-

ments in the function. Potential barriers to taking

part in this study, such as the difficulty of doing

something new or not being interested in computer

games, did not prevent any participant from attend-

ing or completing the study. Even the participant

who was conscious of deteriorating function com-

pleted the programme and described it as interesting

and challenging. Our participants had little prior

experience with using computers for games. The

amount of previous exposure to computers and/or

computer gaming may be one factor influencing

people’s willingness to be involved with VR as

a rehabilitation modality. Prior exposure to compu-

ters was not discussed by all participants, so this

issue would need to be canvassed more fully in

future studies. A further area for investigation is the

potential influence of gender on enjoyment of the VR

environment. As we had only one female participant,

this issue would need to be explored in a larger pool

of female participants.

Although the level of difficulty and pace of

progression through the games were set by the

researchers in response to each participant’s needs,

most participants set themselves goals and targets

within each game. VR games that allow users to

develop strategies to achieve a goal appear to be more

engaging and stimulating [41]. Participants in the

current study used a variety of strategies to complete

the games successfully, including sacrificing accuracy

to increase speed and adjusting body position. Some

of these strategies may run counter to the objectives

of the intervention if a particular or isolated move-

ment is desired. The presentation of clear objectives

and close monitoring of participants may be required

to ensure that participants are completing the

intervention as desired.

The importance of stretching oneself is consistent

with the findings of other studies that have examined

the experiences of adults with chronic stroke trialling

VR programmes. Physical and cognitive challenges

and visual feedback of performance have been

previously identified as components of VR games

that are important to users’ enjoyment [41]. Simi-

larly, following use of a VR intervention designed to

provide a leisure experience rather than pilot a

rehabilitation programme, the participants spoke

of the sense of achievement and feedback they

received about their performance and expressed that

these factors were enjoyed and were important to

them [42].

Our findings contrast with those of Farrow and

Reid [42], as although participants in the current

study found it fun to take part, they were not

interested in using VR purely as a game. Most

participants enjoyed the games, in part, because they

thought their arm function may improve as a result.

A focus group of users in a proposed home-based

VR intervention identified that similar concepts of

finding VR games stimulating and gaining physical

benefits were important as factors likely to motivate

their future involvement [41]. This importance of a

clear purpose of the VR games was highlighted by the

disappointment expressed by one participant in the

current study who felt that the games were not of

benefit as, while they enjoyed improving within the

games, they felt their hand dexterity had deterio-

rated. This disappointment appears to be due to an

expectation that all upper limb impairments would

be addressed by the VR games, and, as a result, the

participant stopped home exercises for the duration

of the study. An information sheet had been

provided to all participants that advised the pilot

programme was focussed on arm movement and

function. It is noted that two other participants also

commented that they hoped their hand function

would improve. Accordingly, there appears to be a

discrepancy between what aspects of upper limb

impairment the intervention proposed to address

and some participants’ expectations of what could or

would be achieved by taking part. Identifying

participants’ priorities and expectations during

screening following clear communication regarding

the nature of the intervention, and what changes in

function might reasonably be expected over the

course of the study, would be beneficial to reduce

the risk of participants’ expectations not being

satisfied.

Participants’ comments around future improve-

ments centred on reducing distractions and increas-

ing their abilities to be involved in the game by

adjusting the environment or increasing the aware-

ness of achievement. Games in which few points

could be scored were considered by some partici-

pants to provide insufficient positive feedback. One

participant expressed a preference for more interac-

tion with the VR environment and more ‘real world’

games such as those available with Nintendo Wii.

The other participants, who did not have this prior

experience with Wii, expressed satisfaction with

the set-up and environment offered. Participants’

experiences and expectations will influence the

extent to which they are able to be immersed in

Perspectives on virtual reality games for stroke 461

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a VR environment; this was demonstrated by one

participant being distracted by the graphics, as based

on their prior real-world experiences, they perceived

that the propeller movement did not correspond

accurately with the directional changes and speed of

the submarine.

Conclusion

Participants found taking part in this pilot study of

VR games for upper limb rehabilitation enjoyable

and challenging. Feedback suggests that the VR

games may well be motivating and engaging for

future participants and has provided a basis for

further development of the current intervention.

This will include higher scoring games, provision of

scoreboards or leaderboards to highlight progression,

the modification of scoring to accentuate appropriate

movement rather than speed and the ability to select

and amend environments. The participants all

improved in VR game times and scores, although

some participants were unable to attempt the more

complex games due to more severe upper limb

impairment. Despite this improvement in perfor-

mance and the perception of some participants that

their function had improved, there were very limited

differences in the clinical outcome measures for any

of the participants following the 6-week intervention.

New technologies such as VR have a potential place

in routine rehabilitation, but involving the end users

in the design of these systems may yield more

acceptable and accessible approaches.

Declaration of interest

The authors report no conflicts of interest. The

authors alone are responsible for the content and

writing of the paper.

References

1. Jorgensen HS, Nakayama H, Raaschou HO, Vive-Larsen J,

Stoier M, Olsen TS. Outcome and time course of recovery in

stroke. Part II: time course of recovery. The Copenhagen

stroke study. Arch Phys Med Rehabil 1995;76:406–412.

2. Mudie MH, Matyas TA. Upper extremity retraining following

stroke: effects of bilateral practice. J Neurol Rehabil 1996;

10:167–184.

3. Taub E, Wolf SL. Constraint-induced movement techniques

to facilitate upper extremity use in stroke patients. Top Stroke

Rehabil 1997;3:38–61.

4. Whitall J, McCombe Waller S, Silver KHC, Macko RF.

Repetitive bilateral arm training with rhythmic auditory cueing

improves motor function in chronic hemiparetic stroke. Stroke

2000;31:2390–2395.

5. Maclean N, Pound P, Wolfe C, Rudd A. Qualitative analysis

of stroke patients’ motivation for rehabilitation. Br Med J

2000;321:1051–1054.

6. Page SJ, Levine P, Sisto S, Bond Q, Johnston MV. Stroke

patients’ and therapists’ opinions of constraint-induced move-

ment therapy. Clin Rehabil 2002;16:55–60.

7. Jack D, Boian R, Merians AS, Tremaine M, Burdea GC,

Adamovich SV, Recce M, Poizner H. Virtual reality-enhanced

stroke rehabilitation. IEEE Trans Neural Syst Rehabil Eng

2001;9:308–318.

8. Reid D. The influence of a virtual reality leisure intervention

program on the motivation of adult stroke survivors. A pilot

study. Phys Occup Ther Geriatr 2004;21:1–19.

9. Merians AS, Jack D, Boian R, Tremaine M, Burdea GC,

Adamovich SV, Recce M, Poizner H. Virtual reality-augmen-

ted rehabilitation for patients following stroke. Phys Ther

2002;82:898–915.

10. Subramanian S, Knaut LA, Beaudoin C, McFayden BJ,

Feldman AG, Levin MF. Virtual reality environments for

post-stroke arm rehabilitation. J Neuroeng Rehabil 2007;4:20.

11. Page SJ. Intensity versus task-specificity after stroke: how

important is intensity? Am J Phys Med Rehabil 2003;82:730–

732.

12. Carnahan H, Vandervoort AA, Swanson LR. The influence of

summary knowledge of results and aging on motor learning.

Res Q Exerc Sport 1996;67:280–287.

13. van Vliet PM, Wulf G. Extrinsic feedback for motor learning

after stroke: what is the evidence? Disabil Rehabil 2006;

28:831–840.

14. Todorov E, Shadmehr R, Bizzi E. Augmented feedback in a

virtual environment accelerates learning of a difficult motor

task. J Motor Behav 1997;29:147–158.

15. Gordon J. Historical development of neurophysiological

approaches. In: Carr JH, Shepherd RA, Gordon J, editors.

Movement science: foundations for physical therapy in

rehabilitation. Rockville: Aspen Publications Inc.; 1987. pp

2–24.

16. Nudo RJ, Milliken GW, Jenkins WM, Merzenich MM. Use-

dependent alterations of movement representations in primary

motor cortex of adult squirrel monkeys. J Neurosci

1996;16:785–807.

17. Jaffe DL, Brown DA, Pierson-Carey CD, Buckley EL,

Lew HL. Stepping over obstacles to improve walking in

individuals with poststroke hemiplegia. J Rehabil Res Dev

2004;41:283–295.

18. Piron L, Tonin P, Dam M. Virtual environment training

therapy for arm motor rehabilitation. Presence 2005;14:732–

740.

19. Kizony R, Katz N, Weiss PL. Adapting an immersive virtual

reality system for rehabilitation. J Visual Comp Animat

2003;14:261–268.

20. Piron L, Tonin P, Atzori AM, Zucconi C, Massaro C,

Trivello E, Dam M. The augmented-feedback rehabilitation

technique facilitates the arm motor recovery in patients after a

recent stroke. Stud Health Technol Inform 2003;94:265–267.

21. Broeren J, Rydmark M, Stibrant K, Sunnerhagen KS. Virtual

reality and haptics as a training device for movement

rehabilitation after stroke: a single-case study. Arch Phys

Med Rehabil 2004;85:1247–1250.

22. Jang SH, You SH, Hallett M, Cho YW, Park C-M, Cho S-H,

Lee H-Y, Kim T-H. Cortical reorganization and associated

functional motor recovery after virtual reality in patients with

chronic stroke: an experimenter-blind preliminary study. Arch

Phys Med Rehabil 2005;86:2218–2223.

23. Holden MK, Todorov E, Callahan J, Bizzi E. Virtual

environment training improves motor performance in two

patients with stroke: case report. Neurol Rep 1999;23:57–67.

24. Holden MK, Dyar T, Callahan J, Schwamm L, Bizzi E.

Quantitative assessment of motor generalization in the real

world following training in a virtual environment in patients

with stroke. Neurol Rep 2002;25:129–130.

462 G. N. Lewis et al.

Dis

abil

Reh

abil

Ass

ist T

echn

ol D

ownl

oade

d fr

om in

form

ahea

lthca

re.c

om b

y U

nive

rsity

of

Cal

gary

on

08/3

1/14

For

pers

onal

use

onl

y.

25. Stewart JC, Yeh S-C, Jung Y, Yoon H, Whitford M, Chen

S-Y, Li L, McLaughlin M, Rizzo AA, Winstein CJ. Interven-

tion to enhance skilled arm and hand movements after

stroke: a feasibility study using a new virtual reality system.

J Neuroeng Rehabil 2007;4:21.

26. Deutsch JE, Latonio J, Burdea GC, Boian R. Post-stroke

rehabilitation with the Rutgers Ankle system: a case study.

Presence 2001;10:416–430.

27. Weiss PL, Naveh Y, Katz N. Design and testing of a virtual

environment to train stroke patients with unilateral spatial

neglect to cross a street safely. Occup Ther Int 2003;10:39–

55.

28. Olsen TS. Arm and leg paresis as outcome predictors in stroke

rehabilitation. Stroke 1990;21:247–251.

29. Jorgensen HS, Nakayama H, Raaschou HO, Olsen TS.

Stroke. Neurologic and functional recovery the Copenhagen

Stroke Study. Phys Med Rehabil Clin N Am 1999;10:887–

906.

30. Fugl-Meyer AR, Jaasko L, Leyman I, Olsson S, Steglind S.

The post-stroke hemiplegic patient. Part I. A method for

evaluation of physical performance. Scand J Rehabil Med

1975;7:13–31.

31. Mathiowetz V, Volland G, Kashman N, Weber K. Adult

norms for the Box and Block Test of manual dexterity. Am J

Occup Ther 1985;39:386–391.

32. Chin JP, Diehl VA, Norman KL. Development of an

instrument measuring user satisfaction of the human–compu-

ter interface. Proceeding of the CHI’88 conference on human

factors in computing systems. New York: ACM Press; 1988.

33. Sandelowski M. Whatever happened to qualitative descrip-

tion? Res Nurs Health 2000;23:334–340.

34. Hsieh HF, Shannon SE. Three approaches to qualitative

content analysis. Qual Health Res 2005;15:1277–1288.

35. Cameirao M, Badia S, Oller E, Verschure P. Neurorehabilita-

tion using the virtual reality based rehabilitation gaming

system: methodology, design, psychometrics, usability and

validation. J Neuroeng Rehabil 2010;7:48.

36. Piron L, Turolla A, Tonin P, Piccione F, Lain L, Dam M.

Satisfaction with care in post-stroke patients undergoing a

telerehabilitation programme at home. J Telemed Telecare

2008;14:257–260.

37. Lourenco CB, Azeff L, Sveistrup H, Levin MF. Effect of

environment on motivation and sense of presence in healthy

subjects performing reaching tasks. 2008 Virtual rehabilita-

tion, IWVR; 2008.

38. Maclean N, Pound P, Wolfe C, Rudd A. The concept of

patient motivation: a qualitative analysis of stroke profes-

sionals’ attitudes. Stroke 2002;33:444–448.

39. Taub E, Miller NE, Novack TA, Cook EW, Fleming WC,

Nepomuceno CS, Connell JS, Crago JE. Technique to

improve chronic motor deficit after stroke. Arch Phys Med

Rehabil 1993;74:347–354.

40. Uswatte G, Qadri LH. A behavioral observation system for

quantifying arm activity in daily life after stroke. Rehabil

Psychol 2009;54:398–403.

41. King M, Hale L, Pekkari A, Persson M, Gregorsson M,

Nilsson M. An affordable, computerised, table-based exercise

system for stroke survivors. Disabil Rehabil Assist Technol

2010;5:288–293.

42. Farrow S, Reid D. Stroke survivors’ perceptions of a leisure-

based virtual reality program. Technol Disabil 2004;16:69–

81.

Perspectives on virtual reality games for stroke 463

Dis

abil

Reh

abil

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ownl

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d fr

om in

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ahea

lthca

re.c

om b

y U

nive

rsity

of

Cal

gary

on

08/3

1/14

For

pers

onal

use

onl

y.