Cognitive-motor exergame training on a labile surface in stroke inpatients: study protocol for a randomized controlled trial

 Labile is an adjective used to describe something that is easily or frequently changed.

 

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Cognitive-motor exergame training on a labile surface in stroke inpatients: study protocol for a randomized controlled trial

Joel Büttiker¹Detlef Marks²Manuel Hanke³Sebastian Ludyga³Petra Marsico⁴Benjamin Eggimann⁵Eleftheria Giannouli^1*

• ¹Department of Health Sciences and Technology, ETH Zurich, Zurich, Switzerland
• ²Rehaklinik Zihlschlacht, Centre for Neurological Rehabilitation, Zihlschlacht, Switzerland
• ³Department of Sport, Exercise and Health, University of Basel, Basel, Switzerland
• ⁴Research Department, Swiss Children’s Rehab, University Children’s Hospital Zurich, Zurich, Switzerland
• ⁵OST – Eastern Switzerland University of Applied Sciences, Rapperswil, Switzerland

Background: Cognitive-motor training in form of exergames has been found to be feasible and effective for the improvement of motor and cognitive functioning in older adults and several patient populations. Exergame training under unstable conditions might increase the proprioceptive resources needed and thus might be a superior training approach compared to exergame training on stable ground for stroke patients, who often have proprioceptive deficits.

Objective: Aim of this study is to assess the feasibility and effects of exergame-based cognitive-motor training on a labile platform on physical and cognitive functioning in stroke inpatients.

Methods: This is two-armed pilot randomized controlled trial taking place in an inpatient neurologic rehabilitation clinic. A total of 30 persons that are undergoing inpatient rehabilitation due to a stroke will be randomly assigned to either the intervention group (IG) or the control group (CG). Participants of the IG will receive exergame-based motor-cognitive training on a labile surface, whereas participants of the CG will train on a stable surface. Primary outcome is feasibility comprising measures of adherence, attrition, safety and usability. Secondary outcomes will be measures of cognitive (psychomotor speed, inhibition, selective attention, cognitive flexibility, brain activity) and motor (functional mobility, gait speed, balance, proprioception) functioning.

Results: Data collection started in February 2024 and is expected to be completed by August 2024.

Conclusion: This is the first study looking into exergame training on labile surface in stroke patients. It will give valuable insights into the feasibility and potential added value of this type of training and thus inform further implementation efforts in the context of inpatient rehabilitation.

Clinical trial registration: ClinicalTrials.gov, NCT06296069.

1 Introduction

With the growing number of older adults due to the demographic shift, the risk of cardiovascular and neurologic diseases and especially stroke rises (1). Due to an increasing prevalence and a shift to younger age groups, stroke is the second-leading cause of death and third-leading cause of death and disability combined worldwide (2). The inpatient care, rehabilitation and follow up care of stroke patients is over 3% of the value of lost welfare/gross domestic product in certain regions (3). Twenty-six percent of the persons who suffered a stroke remain with limited ability to perform activities of daily living (ADLs) and 50% have reduced mobility due to hemiparesis (4). Post-stroke cognitive impairment (PSCI) is the occurrence of cognitive deterioration after a stroke, which can range from minor impairment to dementia. Studies show that PSCI occurs in up to 60% (cumulative incidence) in the first year (5) as well as 10 years (6) after stroke. PSCI can severely limit the motor and cognitive functioning of the patients and reduce their independence by affecting memory, attention and executive functions (7). Furthermore, the presence of any degree of cognitive impairment (MCI) be a risk factor for falls and other comorbidities of the musculoskeletal system (8).

As a result of the impairment in cognitive and motor functioning after a stroke, the balance ability worsens and gait becomes unsteady. Of all complications following a stroke, falls are one of the most prevalent. Between 14–65% of people with stroke fall at least once during hospitalization and between 37–73% fall during the first six-months after discharge (9). Fall risk is up to two times higher even at later stages after stroke compared to similarly aged individuals (10). Thus, there is also an increased need for interventions in this population.

Balance training is an established form of exercise in people suffering from stroke and other neurological disabilities (11). However, cognitive-motor training is superior to single physical training in improving motor functioning, e.g., gait speed and walking endurance in stroke patients (12). More specifically, compared to sequential (e.g., cycling followed by cognitive training) and simultaneous-additional (e.g., cycling while solving an arithmetical task), simultaneous-incorporated motor-cognitive training (e.g., any type of training in which the cognitive task is “incorporated” into the motor task, i.e., the cognitive task is a relevant prerequisite to successfully solve the motor-cognitive task) (13) seems to be the most promising training type for improving gait speed, walking endurance, cadence and stride length in stroke patients (12).

Exergames (video games which are played by body movements) are an excellent tool for the delivery of simultaneous-incorporated cognitive-motor training and they have already been used in the context of several frail and neurologic populations (14–18), including stroke patients (19, 20).

Proprioception is used to stabilize the body by sensing its position in space via the sense of joint and limb positioning. Proprioception training addresses the balance and somatosensory stimulation and can therefore build a possible prevention strategy for further falls and of managing ADLs (21). Combining proprioceptive training with simultaneous cognitive tasks could have additional positive outcomes in stroke rehabilitation. Indeed, a recent systematic review concluded that proprioceptive combined with dual-task exercises stimulate and promote postural balance, gait, and quality of life and reduce the risk of falls in stroke patients compared with traditional rehabilitation programs (22).

There is currently just one study that has looked into the effects of exergame-based cognitive-motor training with the additional proprioceptive stimulation by playing the exergames on a labile platform (23). They found that compared to the training on a stable platform and to a passive control group, training on an instable platform is more effective for the improvement of reactive balance and functional mobility under dual-task conditions in healthy, community-dwelling older adults. The feasibility and effects of this type of exergame training on labile surface and thus rich in proprioceptive stimulation in stroke patients remains unknown.

Therefore, the aim of this study is to assess the feasibility and effects of exergame-based cognitive-motor training on a labile platform on physical and cognitive functioning in stroke inpatients.

We hypothesize that exergame-based cognitive-motor on a labile surface will be feasible within the context of inpatient rehabilitation of stroke patients. In addition, we hypothesize that compared to training on stable surface, training on a labile platform will be more effective for the improvement of motor and cognitive functioning in stroke inpatients.

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