No clue what this is, so ask your competent? doctor if this will get you recovered.
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The influence of scaffolding on intrinsic motivation and autonomous adherence to a game-based, sparsely supervised home rehabilitation program for people with upper extremity hemiparesis due to stroke. A randomized controlled trial
Journal of NeuroEngineering and Rehabilitation volume 21, Article number: 143 (2024)
Abstract
Background
This parallel, randomized controlled trial examined intrinsic motivation, adherence and motor function improvement demonstrated by two groups of subjects that performed a 12-week, home-based upper extremity rehabilitation program. Seventeen subjects played scaffolded games, presenting eight to twelve discrete levels of increasing difficulty. Sixteen subjects performed the same activities controlled by success algorithms that modify game difficulty incrementally.
Methods
33 persons 20–80 years of age, at least 6 months post stroke with moderate to mild hemiparesis were randomized using a random number generator into the two groups. They were tested using the Action Research Arm Test, Upper Extremity Fugl Meyer Assessment, Stroke Impact Scale and Intrinsic Motivation Inventory pre and post training. Adherence was measured using timestamps generated by the gaming system. Subjects had the Home Virtual Rehabilitation System (Qiu in J Neuroeng Rehabil 17: 1–10, 2020) placed in their homes and were taught to perform rehabilitation games using it. Subjects were instructed to train twenty minutes per day but were allowed to train as much as they chose. Subjects trained for 12 weeks without appointments and received intermittent support from study staff. Group outcomes were compared using ANOVA. Correlations between subject demographics and adherence, as well as motor outcome, were evaluated using Pearson Correlation Coefficients.
Results
There were 5 dropouts and no adverse events. The main effect of time was statistically significant for four of the five clinical outcome measures. There were no significant training group by time interactions. Measures of adherence did not differ significantly between groups. The combined groups improved their UEFMA scores on average by 5.85 (95% CI 4.73–6.98). 21 subjects from both groups demonstrating improvements in UEFMA scores of at least 5 points, exceeding the minimal clinically important difference of 4.25. IMI scores were stable pre to post training.
Conclusions
Scaffolding challenges during game based rehabilitation did not elicit higher levels of adherence when compared to algorithm control of game difficulty. Both sparsely supervised programs of game-based treatment in the home were sufficient to elicit statistically significant, clinically meaningful improvements in motor function and activities of daily living.
Trial registration: Clinical Trials.gov—NCT03985761, Registered June 14, 2019.
Introduction
Despite decades of research attempting to remediate upper extremity impairments following stroke, a rehabilitation approach that elicits substantial improvements in function that do not decay over time has not been developed [2]. This points to a need for opportunities for persons with residual impairments following stroke to work on their arm and hand function away from the clinical environment with relative independence [3]. The use of traditional and technology-supported home-based rehabilitation programs has increased steadily in the last two decades and was further accelerated by the COVID–19 pandemic [4]. Short term and directly supervised telerehabilitation programs produce outcomes comparable to those of clinic-based treatments [5, 6]. Longer programs and sparsely supervised programs have not been studied as well, and outcomes are less consistent. In general, adherence to programs of activity designed to improve or maintain motor function following a stroke is relatively low [7]. Multiple barriers to consistent performance of motor function training activities exist, including low motivation as well as a lack of interest in, or enjoyment of, training activities [8]. Multiple authors have proposed that game-based rehabilitation activities may help overcome these barriers and provide a solution to low adherence to home based rehabilitation programs [9,10,11]. This said, the published evidence presents a range of adherence rates to gamified, home based rehabilitation, suggesting that simply presenting a rehabilitation activity as a game might not result in across the board improvements in adherence [9, 12,13,14,15,16,17]. Multiple factors have been identified as possible causes for varied adherence to technology supported rehabilitation interventions in the home [9, 18, 19].
The gaming industry utilizes a wide variety of gaming mechanics, processes that govern the way a game flows, information is presented, and player success or failure is communicated. This influences the frequency with which players pick up a game and play it, as well as the amount of time they play a game after initiating [20]. This study focused on scaffolding, a very common gaming mechanism that presents a relatively easy version of a game, followed by gradually ascending levels of difficulty as a participant succeeds [21]. This affords the participant immediate initial feelings of self-efficacy and then proceeds to challenge them. Appropriate levels of challenge [22] and feelings of self-efficacy [23] are both associated with higher levels of motivation, as is the clear knowledge of results feedback [22] a participant receives when they are presented with a new challenge after they succeed or they are required to repeat a level if they fail.
This study utilized a parallel randomized clinical trial to examine the adherence levels of subjects with stroke performing a 12-week, home-based upper extremity rehabilitation program incorporating simulations that used scaffolding to that of a control group of subjects that performed the same activities controlled by success algorithms that increase and decrease game difficulty incrementally and undetectably [24, 25]. Our overall study question focused on autonomous adherence to the training program by setting the subjects up with the system and having them perform their training without direct supervision or appointments. The primary analysis focused on the impact of scaffolding on adherence, by tracking total treatment time using system-collected measurement of actual game play frequency. Secondary analyses examined (1) the effect of scaffolding on motivation by analyzing pre and post training Intrinsic Motivation Inventory scores and (2) the effectiveness of the training programs using clinical measures of upper extremity function and self-reported measures of hand function and activities of daily living.
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