Exergames as a rehabilitation tool to enhance the upper limbs functionality and performance in chronic stroke survivors: a preliminary study

Ask your doctor to get the protocols for this. FAILURE IS NOT AN OPTION!

Exergames as a rehabilitation tool to enhance the upper limbs functionality and performance in chronic stroke survivors: a preliminary study

Luca Vismara^1†Claudia Ferraris^2*†Gianluca Amprimo^2,3Giuseppe Pettiti²Francesca Buffone^4,5Andrea Gianmaria Tarantino⁴Alessandro Mauro^1,6Lorenzo Priano^1,6

• ¹Division of Neurology and Neurorehabilitation, Istituto Auxologico Italiano IRCCS, S. Giuseppe Hospital, Piancavallo, Italy
• ²Institute of Electronics, Information Engineering and Telecommunication, National Research Council, Turin, Italy
• ³Department of Control and Computer Engineering, Politecnico di Torino, Turin, Italy
• ⁴Division of Paediatric, Manima Non-Profit Organization Social Assistance and Healthcare, Milan, Italy
• ⁵Principles and Practice of Clinical Research, Harvard T.H. Chan School of Public Health–ECPE, Boston, MA, United States
• ⁶Department of Neurosciences “Rita Levi Montalcini”, University of Turin, Turin, Italy

Introduction: Post-stroke hemiplegia commonly occurs in stroke survivors, negatively impacting the quality of life. Despite the benefits of initial specific post-acute treatments at the hospitals, motor functions, and physical mobility need to be constantly stimulated to avoid regression and subsequent hospitalizations for further rehabilitation treatments.

Method: This preliminary study proposes using gamified tasks in a virtual environment to stimulate and maintain upper limb mobility through a single RGB-D camera-based vision system (using Microsoft Azure Kinect DK). This solution is suitable for easy deployment and use in home environments. A cohort of 10 post-stroke subjects attended a 2-week gaming protocol consisting of Lateral Weightlifting (LWL) and Frontal Weightlifting (FWL) gamified tasks and gait as the instrumental evaluation task.

Results and discussion: Despite its short duration, there were statistically significant results (p < 0.05) between the baseline (T0) and the end of the protocol (TF) for Berg Balance Scale and Time Up-and-Go (9.8 and −12.3%, respectively). LWL and FWL showed significant results for unilateral executions: rate in FWL had an overall improvement of 38.5% (p < 0.001) and 34.9% (p < 0.01) for the paretic and non-paretic arm, respectively; similarly, rate in LWL improved by 19.9% (p < 0.05) for the paretic arm and 29.9% (p < 0.01) for non-paretic arm. Instead, bilateral executions had significant results for rate and speed: considering FWL, there was an improvement in rate with p < 0.01 (31.7% for paretic arm and 37.4% for non-paretic arm), whereas speed improved by 31.2% (p < 0.05) and 41.7% (p < 0.001) for the paretic and non-paretic arm, respectively; likewise, LWL showed improvement in rate with p < 0.001 (29.0% for paretic arm and 27.8% for non-paretic arm) and in speed with 23.6% (p < 0.05) and 23.5% (p < 0.01) for the paretic and non-paretic arms, respectively. No significant results were recorded for gait task, although an overall good improvement was detected for arm swing asymmetry (−22.6%). Hence, this study suggests the potential benefits of continuous stimulation of upper limb function through gamified exercises and performance monitoring over medium-long periods in the home environment, thus facilitating the patient's general mobility in daily activities.

1 Introduction

Stroke is a clinical syndrome characterized by acute loss of focal brain function, with symptoms lasting longer than 24 h or bearing to death, caused by reduced or interrupted blood supply to a brain area (ischemic stroke) or bleeding inside brain parenchyma (hemorrhagic stroke). Despite advances in wellness, prevention, and treatment, there is an increasing incidence of stroke events in the global population, as reported by several global reports (1, 2). In addition to well-known risk factors, aging is one of the more relevant non-modifiable conditions: reports indicate that incidence doubles with age (3). The consequences of the acute event are the leading causes of various functional deficits, both in the physical and cognitive domains, resulting in a significant long-term burden on healthcare systems (4) and poor quality of life for stroke survivors (5). Indeed, stroke survivors exhibit typical motor disabilities that limit their overall mobility, directly impacting activities of daily living and active social participation (6). Specifically, hemiparesis of the contralateral upper limb is one of the most disabling manifestations: this impairment affects more than 80% of stroke survivors, causing an acute or chronic limitation of mobility, control, and coordination in the upper limbs that hinders common daily actions (e.g., reaching and picking up objects) (7). Moreover, it has been shown that the upper limbs influence gait due to the altered coordination and limited stability, being an important aspect that prevents the achievement of a normal walking speed (8).

After the acute event, specific rehabilitation protocols are promptly activated to restore lost functions, activate compensatory strategies, and improve patients' independence in daily life. Some rehabilitative therapies focus on gait, posture, and balance to reduce the risk of falls and improve patient safety (9–11). Focusing on the upper limbs, several studies pointed out how therapies based on physical exercises play a crucial role after stroke: ad-hoc strategies are commonly established by varying the duration, workload, and frequency according to the patient's condition and implementing dedicated training sessions based on goal-, task-, or repetition-oriented approaches (6). For example, bilateral training (i.e., exercises that stress both sides concurrently) is a recent strategy to improve motor coordination that is based on well-established knowledge. Indeed, with this approach, the non-paretic arm can stimulate the motor function of the paretic arm when simultaneous movements are performed (12).

Recently, training and rehabilitation of the upper limb through technological approaches have gained increasing interest, and various solutions have been proposed to address the severity of motor impairment in post-stroke conditions. The most widely adopted technological solutions mainly involve assistive devices (13) and robots (14, 15) exploit for the most severe conditions. Several innovative methodologies for less severe conditions include virtual reality (16, 17); serious games, exergames, and gamification techniques (14, 18); and motion tracking using vision-based systems (19–23).

In this context, we present a solution for proposing and monitoring physical activities based on gamified tasks and exercises suitable for domestic use. The primary goal is to solicit upper limb mobility through gamified tasks promoting the improvement or maintenance of upper limb motor functions, including range of motion, motor control, and coordination. The gamified tasks are offered in two modes, unilateral and bilateral execution, and can be appropriately configured for game difficulty according to subjects' motor conditions. One of the platforms implemented during the REHOME project (24) was used for the study, specifically the Motor Rehabilitation and Exergames platform (MREP) (25). MREP leverages a single RGB-Depth camera (specifically, Microsoft Azure Kinect DK) and its innovative body tracking algorithm that captures body movements in real-time through a deep learning approach. Several works have recently analyzed the performance of the device compared with gold-standard motion capture systems (MOCAP), verifying its higher accuracy compared with predecessors and other optical sensors (26–28). Other studies have also analyzed the performance of the new body-tracking algorithm, verifying its accuracy, robustness, and reliability in capturing 3D movements and poses (29–31), including the analysis of the upper limb mobility (32–34). The good agreement with MOCAPs has led to using Azure Kinect in preliminary clinical studies and rehabilitation protocols (35–38). MREP offers various exercises (grouped into assessment tasks, gamified tasks, and rehabilitative exergames) to automatically assess upper and lower limb motor impairment related to neurological disorders. However, for the purposes of this preliminary study, we included only two of the available gamified tasks and one of the assessment tasks (i.e., walking) in the experimental protocol since we intended to focus only on upper limb stimulation using gamified tasks to evaluate the potential benefits on arm swing during walking on stroke survivors, as previously done on subjects with Parkinson's disease (39). The results obtained on the cohort of stroke survivors highlight the overall improvement in upper limb mobility for both the paretic and non-paretic arms. In particular, substantial improvement in speed, number of movements per minute, coordination metrics, and reduction of asymmetry in arm swing during walking was observed, thus confirming the initial hypothesis of the potential benefits of physical activities using gamified tasks. In addition, an implicit adaptation of the performance of the non-paretic arm to the paretic arm was also observed, as in (6). It is relevant to note that these findings agree with the overall clinical improvement (scales and tests) assessed at the end of the experimental protocol, despite the specific treatment response shown by each participant. Hence, this preliminary study aimed to evaluate whether a limited number of training sessions (precisely six) with exergames could, however, contribute to improving the functionality and performance of the upper limbs in post-stroke patients over a relatively short period (2 weeks): the positive and promising results obtained from the experimental study seem to confirm this trend.

More at link.