Integration of music-based game approaches with wearable devices for hand neurorehabilitation: a narrative review

 I bet your competent? doctor still hasn't created a music protocol for your recovery! And you're still seeing them?

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Integration of music-based game approaches with wearable devices for hand neurorehabilitation: a narrative review

• Javier Urbina,
• Victoria E. Abarca &
• Dante A. Elias 

Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 89 (2024) Cite this article

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Abstract

Background

Restoring hand functionality is critical for fostering independence in individuals with neurological disorders. Various therapeutic approaches have emerged to address motor function restoration, with music-based therapies demonstrating notable advantages in enhancing neuroplasticity, an integral component of neurorehabilitation. Despite the positive effects observed, there remains a gap in the literature regarding implementing music treatments in neurorehabilitation, such as Neurologic Music Therapy (NMT), especially in conjunction with emerging fields like wearable devices and game-based therapies.

Methods

A literature search was conducted in various databases, including PubMed, Scopus, IEEE Xplore, and ACM Digital Library. The search was performed using a literature search methodology based on keywords. Information collected from the studies pertained to the approach used in music therapy, the design of the video games, and the types of wearable devices utilized.

Results

A total of 158 articles were found, including 39 from PubMed, 34 from IEEE Xplore, 48 from Scopus, 37 from ACM Digital Library, and 35 from other sources. Duplicate entries, of which there were 41, were eliminated. In the first screening phase, 152 papers were screened for title and abstract. Subsequently, 89 articles were removed if they contained at least one exclusion criterion. Sixteen studies were considered after 63 papers had their full texts verified.

Conclusions

The convergence of NMT with emerging fields, such as gamification and wearable devices designed for hand functionality, not only expands therapeutic horizons but also lays the groundwork for innovative, personalized approaches to neurorehabilitation. However, challenges persist in effectively incorporating NMT into rehabilitation programs, potentially hindering its effectiveness.

Introduction

Neurological disorders are a group of heterogeneous diseases, some of which contribute to gait, balance, and strength problems that result in a lower quality of life. They affect nearly one billion people globally and comprise 6.3% of the worldwide disease burden [1]. Representative cases in this group are stroke, multiple sclerosis, cerebral palsy, spinal cord injury (SCI), and Parkinson’s disease (PD) [2]. These disorders can lead to significant deterioration in hand function, one of the most complex anatomical structures, and crucial in the human capacity for executing activities of daily living [3]. Particularly in individuals with these conditions, due to the significant deterioration in hand function, the ability to reach, grasp, release, and move objects effectively is frequently affected as a result of impairments of upper extremity function: reduced muscle strength, sensory loss, increased muscle stiffness, and a lack of motor control [4].

One of the primary methods of recovery after a neurological injury is neuroplasticity [5]. This phenomenon is defined as the capacity of the human brain to adapt and reconfigure its neuronal connections in response to diverse experiences [6]. When changes in the brain are connected to dysfunctional outcomes for the individual, it is termed maladaptive neural plasticity [7], such as neurological disorders. Conversely, when alterations in the brain are correlated with enhancements in an individual’s behavioral capabilities, this phenomenon is termed adaptive neural plasticity [7]. Some examples of the appearance of adaptive neural plasticity are during brain development [8] and motor skills learning [9]. As a result, ongoing research is dedicated to devising innovative treatments that can enhance neuroplasticity to rehabilitate patients with neurological disorders.

Evidence supports the effectiveness of including intensive, repetitive, challenging, and task-specific practices in interventions aimed at fostering neuroplasticity(But you have NO CLUE on how to make neuroplasticity repeatable on demsnd!) and augmenting sensorimotor recovery [10,11,12,13]. Furthermore, Petzinger et al. [12] underscore the significance of cognitive engagement as another critical component for enhancing plasticity. These authors suggest that cognitive engagement might be improved by feedback, attentional demand through cueing, and motivation. Cueing is described as utilizing external temporal or spatial stimuli to aid in initiating and sustaining movement [14].

Standard neurorehabilitation techniques for upper limb movement primarily depend on physical therapy [15]. This therapy involves targeted exercises designed to restore the functioning of the affected portion of the motor system [16]. Unfortunately, traditional occupational therapy in its current form is a process that patients dislike going through [17], as it proves difficult for them to sustain interest in repetitive exercise routines while simultaneously focusing on the precision of their movements (e.g., speed, precision, fluidity, and posture) [18, 19] and assumes greater significance considering that a patient’s attitude during physical therapy sessions is closely related to their compliance and success [20]. Children are significantly more problematic in this area since it is challenging to maintain their motivation throughout protracted therapy sessions [21]. Moreover, heightened patient motivation in their ultimate objective is a crucial facet of neuroplasticity [22]. Therefore, based on the reviewed literature, it can be inferred that effective strategies for improving neuroplasticity in neurorehabilitation should involve elements such as intensity, repetition, challenges, task-specificity, and cognitive engagement, among others.

Consequently, in upper limb neurorehabilitation, many therapy options have emerged. Lin et al. [23] realized a review of experimented training programs designed to enhance motor recovery following a stroke; these include Constraint-Induced Movement Therapy, Electromyography biofeedback, Motor imagery therapy, Robot-assisted training, Virtual reality or gaming, etc. These treatment options must incorporate the abovementioned components to promote neuroplasticity in patients.

In the quest to provide hand neurorehabilitation with intensive, repetitive, and task-specificity practices for the patient, taking into account their limitations and strengths, it is of paramount importance to assess hand functionality during therapies, as it enables the identification of changes indicating neurological decline or the tracking of responses to treatments [24]. In this regard, motion capture devices gain greater significance. Camera-based systems and keyboard-based methods, such as the Musical Instrument Digital Interface (MIDI), are widely used for movement assessment in rehabilitation. Notable studies include those employing the leap motion controller, such as a 2019 study on PD by Fernández-González et al. [25] and a study on stroke by Shah et al. [26]. Additionally, studies have used keyboards by Altenmüller in 2009 [27] and Villeneuve in 2013 [28]. However, wearable devices distinguish themselves by assessing user movement and providing assistance during rehabilitation. For instance, wearable robotic devices outperform traditional therapy due to their ability to provide a higher number of repetitions in each session, objectively assess the patient’s performance, reduce the physical strain on therapists, and enable the monitoring of the patient’s active participation in the training regimen [29]. In the same way, non-robotic wearable devices, such as data gloves, are effective instruments for tracking hand movements and evaluating hand functionality within hand rehabilitation systems [30].

One practical approach to enhancing cognitive engagement involves the use of auditory cueing. One emerging rehabilitation process that uses auditory cues is music therapy, specifically neurological music therapy (NMT) [31]. NMT is one of the few clinical interventions utilizing music as a primary rehabilitative stimulus to evoke diverse brain and motor responses [32]. Additionally, evidence suggests that musical treatments provide a therapeutic strategy for recovering functional capacities in the upper extremities of individuals with neurological disorders [33]. This is accentuated by its reliance on a research-based system of standardized clinical techniques for sensorimotor, speech/language, and cognitive training [34].

Thaut and Hoemberg [35] have classified NMT into twenty techniques, from which three address motor rehabilitation: Rhythmic Auditory Stimulation (RAS), Patterned Sensory Enhancement (PSE), and Therapeutic Instrumental Music Performance (TIMP). RAS enhances motor control by applying rhythmic sensory stimulation in rehabilitating movements with inherent biological rhythmicity, such as gait [35]. Although RAS has been extensively studied for gait neurorehabilitation, especially on PD [36], it is also applied to upper limb rehabilitation. Ghai et al. [37] realized a systematic review and meta-analysis to analyze the effects of rhythmic auditory cueing on arm function recovery post-stroke, in which beneficial effects on the Fugl Meyer test, Action reach arm test and Wolf motor time test were reported. PSE is utilized for movements that do not inherently follow a rhythm, such as typical arm and hand motions. Besides employing rhythm and timing as cues for movement, like RAS, PSE utilizes intricate patterned structures in music to organize multiple smaller motions to accomplish a more extensive sequence of movements [35]. An investigation led by Wang et al. [38] within a home-based program employing PSE reveals significant enhancements in the gross motor capacity of children with cerebral palsy. Likewise, in a recent study by Fan et al. [39], individuals with PD demonstrated enhanced speed and functionality in upper-limb movements by integrating PSE. Finally, TIMP uses musical instruments to assist patients in regaining effective movement patterns and exercising compromised motor function [35]. According to Pascual-Leone, playing a musical instrument demands extensive procedural and motor learning that results in the plastic reorganization of the human brain, which further supports the potential of music therapy in rehabilitation [40]. A systematic review performed by Yang et al. in 2022 summarizes the effect of NMT in patients with cerebral palsy. It suggests the effect of TIMP in enhancing both gross and fine motor skills, with a particular focus on improving hand function and the power associated with piano key pressing [41].

A growing aspect highlighted in Lin et al.’s [23] review of neurological rehabilitation is the incorporation of gaming, specifically the integration of gamification. Gamification is characterized as implementing game-related components in settings that extend beyond traditional gaming contexts [42]. It is suggested that incorporating gamification into neurorehabilitation has the potential to tackle various challenges related to the implementation of intensive, engaging, and cost-effective therapeutic exercises [43], even promoting motivation [44]. Games introduce challenges to patients, transforming rehabilitation into a dynamic and appealing journey [45]. Numerous research groups have advocated integrating video games as a supplementary tool alongside traditional neurorehabilitation therapy [46].

In summary, there is a need to develop innovative approaches for delivering therapeutic exercises, especially for hand neurorehabilitation. Gathering evidence in rehabilitating neurological disorders and enhancing neuroplasticity and patient adherence underscores that interventions integrating repetitive, intensive, challenging, and motivational tasks are highly likely to improve functional recovery. For this reason, this narrative review aims to investigate the effectiveness of music and game-based approaches, hand functionality assessment, and assistance by wearable devices in achieving neuroplasticity for successful hand neurorehabilitation.