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Music meets robotics: a prospective randomized study on motivation during robot aided therapy
Journal of NeuroEngineering and Rehabilitation volume 15, Article number: 79 (2018)
Abstract
Background
Robots have been successfully applied in motor training during neurorehabilitation. As music is known to improve motor function and motivation in neurorehabilitation training, we aimed at integrating music creation into robotic-assisted motor therapy. We developed a virtual game-like environment with music for the arm therapy robot ARMin, containing four different motion training conditions: a condition promoting creativity (C+) and one not promoting creativity (C–), each in a condition with (V+) and without (V–) a visual display (i.e., a monitor). The visual display was presenting the game workspace but not contributing to the creative process itself. In all four conditions the therapy robot haptically displayed the game workspace. Our aim was to asses the effects of creativity and visual display on motivation.
Methods
In a prospective randomized single-center study, healthy participants were randomly assigned to play two of the four training conditions, either with (V+) or without visual display (V–). In the third round, the participants played a repetition of the preferred condition of the two first rounds, this time with a new V condition (i.e., with or without visual display). For each of the three rounds, motivation was measured with the Intrinsic Motivation Inventory (IMI) in the subscales interest/enjoyment, perceived choice, value/usefulness, and man-machine-relation. We recorded the actual training time, the time of free movement, and the velocity profile and administered a questionnaire to measure perceived training time and perceived effort. All measures were analysed using linear mixed models. Furthermore, we asked if the participants would like to receive the created music piece.
Results
Sixteen healthy subjects (ten males, six females, mean age: 27.2 years, standard deviation: 4.1 years) with no known motor or cognitive deficit participated. Promotion of creativity (i.e., C+ instead of C–) significantly increased the IMI-item interest/enjoyment (p=0.001) and the IMI-item perceived choice (p=0.010). We found no significant effects in the IMI-items man-machine relation and value/usefulness. Conditions promoting creativity (with or without visual display) were preferred compared to the ones not promoting creativity. An interaction effect of promotion of creativity and omission of visual display was present for training time (p=0.013) and training intensity (p<0.001). No differences in relative perceived training time, perceived effort, and perceived value among the four training conditions were found.
Conclusions
Promoting creativity in a visuo-audio-haptic or audio-haptic environment increases motivation in robot-assisted therapy. We demonstrated the feasibility of performing an audio-haptic music creation task and recommend to try the system on patients with neuromuscular disorders.
Trial registration
ClinicalTrials.gov, NCT02720341. Registered 25 March 2016, https://clinicaltrials.gov/ct2/show/NCT02720341
Background
Following a stroke, 80-90% of patients suffer from arm paresis, which remains chronic in about 30-40% of all cases [1–3]. Task-oriented, intensive, and motivational training is important to increase arm function post-stroke [2, 4–8].
Intensity is recognized as a key feature of successful rehabilitation therapy [9]. Robots in neurorehabilitation allow for highly-intensive, task-oriented training and have the potential to be superior to conventional therapies (i.e., physical or occupational therapy) in improving motor function post-stroke [10]. Robotic therapy may embed functional training tasks into computer games to facilitate motor learning and to stimulate motivation [11].
Autonomy, competence, and relatedness can be regarded as the main components of intrinsic motivation [12, 13]. While extrinsic motivation can be described as a goal-directed drive towards an externally provided reward (e.g., a score in a game), intrinsic motivation is a process oriented and internally provided reward due to a satisfying, interesting, meaningful or enjoyable activity [14, 15]. The knowledge regarding the meaningfulness of an activity is a positive determinant of patient motivation [7]. Thus, for patients, an activity should not only be enjoyable, but also lead to a rehabilitation progress. Furthermore, patient engagement is related to the expected reduction of impairment during game-based therapy in stroke [16].
Activities with a close relation to intrinsic motivation are frequently associated with activities promoting creativity [17–19]. This might be because activities promoting creativity involve one’s own accord, active decision making, and a resulting product, thus satisfying the need of autonomy, competence, and relatedness [12, 20–22].
In addition to encouraging creativity, music is a promising stimulator for intrinsic motivation in the context of rehabilitation [23, 24]. Music effectively promotes post-stroke recovery in motor and cognitive functions, and furthermore in emotional and social domains [25–31]. Studies that compared conventional therapy forms to therapy tasks embedded in active music making revealed that music-associated training increases the level of motivation significantly [24, 32].
Auditory displays have already been determined to be effective for navigation within complex systems [33]. Accordingly, sound is an audible source for navigation through the execution of a task in virtual scenarios without the need for a visual display unit, the advantage being that the visual focus can be on the trained limb rather than a graphical display, thus promoting visuo-motor control [34, 35].
We developed tasks for robot-assisted training of the arm that aim to increase intrinsic motivation with a focussed stimulation of the two aspects: creativity and music. To investigate whether a music condition promoting creativity influences motivation differently than a music condition not promoting creativity, we compared motivational effects of both versions. We investigated the effect of the presence or absence of a visual display for both conditions regarding promotion of creativity. As the training goal of the presented gamified task is to induce high intensity during exercise, the game is operated by repetitive horizontal movements.
For this current study, we designed audio-haptic tasks in a way that they can be performed either with visual display (i.e., a monitor presenting the game workspace) as an audio-visuo-haptic environment or without a visual display as an audio-haptic environment only. To reduce the cognitive load of the participants and have more cognitive resources for creation and decision making processes, we designed the visual display and the haptic environment such that they both presented the same game workspace [36]. Accordingly, the visuals were not essential to complete the audio-haptic task.
Given these related works, the primary hypothesis was that a gamified task promoting creativity embedded in a task for motor therapy increases intrinsic motivation more than a gamified task not promoting creativity. Our second hypothesis was that a gamified task in motor therapy without visual display increases intrinsic motivation more than a gamified task with visual display. Moreover, we hypothesized that promoting creativity and omitting a visual display would increase total training time, free movement time and perceived product value. We further hypothesized that promoting creativity and omitting a visual display would reduce energy expenditure, relative perceived training time and perceived effort.
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