Getting into a 'flow state' will only be possible if we have EXACT PROTOCOLS LEADING TO 100% RECOVERY. Guidelines do not count. Hell, I could easily get into a 'flow state' even if I had 10 million reps to do. I would 'flow' until I got those 10 million reps in.
So,where are the protocols?
Getting into a “Flow” state: a systematic review of flow experience in neurological diseases
Journal of NeuroEngineering and Rehabilitation volume 18, Article number: 65 (2021)
Abstract
Background
Flow is a subjective psychological state that people report when they are fully involved in an activity to the point of forgetting time and their surrounding except the activity itself. Being in flow during physical/cognitive rehabilitation may have a considerable impact on functional outcome, especially when patients with neurological diseases engage in exercises using robotics, virtual/augmented reality, or serious games on tablets/computer. When developing new therapy games, measuring flow experience can indicate whether the game motivates one to train. The purpose of this study was to identify and systematically review current literature on flow experience assessed in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson’s disease. Additionally, we critically appraised, compared and summarized the measurement properties of self-reported flow questionnaires used in neurorehabilitation setting.
Design
A systematic review using PRISMA and COSMIN guidelines.
Methods
MEDLINE Ovid, EMBASE Ovid, CINAHL EBSCO, SCOPUS were searched. Inclusion criteria were (1) peer-reviewed studies that (2) focused on the investigation of flow experience in (3) patients with neurological diseases (i.e., stroke, traumatic brain injury, multiple sclerosis and/or Parkinson’s disease). A qualitative data synthesis was performed to present the measurement properties of the used flow questionnaires.
Results
Ten studies out of 911 records met the inclusion criteria. Seven studies measured flow in the context of serious games in patients with stroke, traumatic brain injury, multiple sclerosis and Parkinson’s disease. Three studies assessed flow in other activities than gaming (song-writing intervention and activities of daily living). Six different flow questionnaires were used, all of which were originally validated in healthy people. None of the studies presented psychometric data in their respective research population.
Conclusion
The present review indicates that flow experience is increasingly measured in the physical/cognitive rehabilitation setting in patients with neurological diseases. However, psychometric properties of used flow questionnaires are lacking. For exergame developers working in the field of physical/cognitive rehabilitation in patients with neurological diseases, a valid flow questionnaire can help to further optimize the content of the games so that optimal engagement can occur during the gameplay. Whether flow experiences can ultimately have positive effects on physical/cognitive parameters needs further study.
Background
Flow experience is a subjective psychological state that people report when they are completely involved in something to the point of forgetting time and their surrounding except the activity itself [1, 2]. During flow, subjective perception of time may change: Time can pass faster or slower and the environment is hardly or no longer perceived. Attention is fully invested in the task at hand, and the person functions at his or her fullest capacity. The flow state was first described by Csikszentmihalyi (1975) as the “optimal experience”. He began his research on flow experiences with the simple question of why people are often highly committed to activities without obvious external rewards. Csikszentmihalyi’s first studies involved interviews with people from different backgrounds such as athletes, chess masters, rock climbers, dancers, composers of music and many more [3]. Csikszentmihalyi and his colleagues developed the “Flow-theory” with general attributes of an optimal experience and its proximal conditions. The Flow-theory proposes nine key characteristics: challenge-skill balance (balance between the challenge of the activity and personal skills), action-awareness merging (involvement in the task; actions become automatic), clear goals (clear idea of what needs to be accomplished), unambiguous feedback (clear and immediate feedback), concentration on task at hand (complete focused on the task), sense of control (clear feeling of control), loss of self-consciousness (no concerns with appearance, focused only the activity), transformation of time (altered perception of time; either speeding up or down), and autotelic experience (the activity is intrinsically rewarding) [2, 4]. Many researchers tried to adapt the Flow-theory [5] and explored predictors and consequences of flow, but its definition and key characteristics as shortly described above, remained largely the same. In fact, a recent paper about flow clearly advocates Csikszentmihalyi’s Flow-theory as the only valid and default conceptualization so far [5].
Because flow experience is associated with elements such as motivation, peak performance, peak experience and enjoyment, the Flow-theory was further explored in various research fields, such as sports, educational science, work and software engineering for gaming [6,7,8,9]. Positive associations were found between athletes’ flow experience and their performance measures, indicating that positive psychological flow states are related to increased levels of performance. In addition, significant prediction of the athletes’ performance could be made based on the level of flow experience during the competition [10].
Attempts to systematically measure flow experience started in the 1990’s. Self-reported flow questionnaires were used to measure flow during specific activities, such as computer interactions among students and accountants [11], and among athletes practicing various sports such as basketball, athletics, hiking, jogging and other types of sports [4]. In the past 30 years, different flow questionnaires were developed [12, 13]. They focussed either on the dispositional or core flow experience (tendency to experience flow in general) [14] or on the state flow experience (flow experience in a specific activity) [4]. This lead to some disagreement in literature about how flow actually should be measured, and as well as to the context and task in which a flow questionnaire should be applied [5].
Interestingly, over the last decade, several computer or tablet-based serious games, and virtual/augmented reality therapeutic training applications have been developed that integrate many of the key flow characteristics mentioned above. Furthermore, various studies evaluated the player’s flow experience with questionnaires when applying these newer technologies [15,16,17]. Serious games are intentionally programmed so that the goals are presented very clearly (i.e., visually through nice icons), and that the requirements of the exercises are adaptable according to the level of player performance. Also, the exercises should be both exciting and attractive enough to maintain the player’s attention. In this way, the player obtains a certain automatic feeling of flow while having full control over his or her actions. These games are sometimes so well designed that one loses track of time. Serious games, robotics, virtual/augmented reality, have found their way into neurorehabilitation [18,19,20,21], and theory of flow experience emerged in recent neurorehabilitation studies [22, 23]. Indeed, serious exergames may have an explicit educational and/or therapeutic purpose and are often designed in such a way that they may also improve cognitive or physical capabilities [22, 24]. Interestingly, exergame developers began to look at new games from the perspective of flow experience in order to adapt the game conditions of the players, and used flow questions to assess the users’ engagement for the new therapy form [23, 25]. To assess flow experience during a therapeutic session with a patient, valid questionnaires are needed which may guide a clinician in adapting the level of difficulty, attractiveness, amount of feedback of an exercise, possibly further attributing to an optimal flow experience. Such optimization of the motor learning environment may enhance therapeutic efficacy during an individual training session.
However, to date, there is no consensus on how flow experience should be measured in neurologically impaired patients. Furthermore, no systematic overview exists so far, about current existing flow questionnaires and their psychometric properties. Therefore, the first aim of the present study was to identify and systematically review current literature on flow experience assessed in patients with acquired neurological diseases such as stroke, traumatic brain injury (TBI), multiple sclerosis (MS) and Parkinson’s disease (PD). The second aim was to critically appraise, compare and summarize the measurement properties of self-reported flow questionnaires used in a neurorehabilitation setting. Since flow experience has been assessed already in neurological rehabilitation and measurement tools exist, we expected these tools to be well validated.
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