The inuence of scaffolding on intrinsic motivation and autonomous adherence to a game-based, unsupervised home rehabilitation program for people with upper extremity hemiparesis due to stroke. A randomized controlled trial.

You don't understand ONE GODDAMN THING ABOUT SURVIVOR MOTIVATION, DO YOU? You create 100% recovery protocols and your survivor will be motivated to do the millions of reps needed because they are looking forward to 100% recovery. GET THERE! 

The problem is stroke researchers are not motivated to solve stroke. What the fuck is your solution to that failure? We still don't know how to motivate stroke medical 'professionals' to solve stroke to 100% recovery!

 The influence of scaffolding on intrinsic motivation and autonomous
adherence to a game-based, unsupervised home rehabilitation program for
people with upper extremity hemiparesis due to stroke. A randomized
controlled trial.

Gerard Fluet fluetge@shp.rutgers.edu
Rutgers, The State University of New Jersey
Qinyin Qiu
Rutgers, The State University of New Jersey
Amanda Gross
Holly Gorin
Rutgers, The State University of New Jersey
Jigna Patel
Rutgers, The State University of New Jersey
Alma Merians
Rutgers, The State University of New Jersey
Sergei Adamovich
New Jersey Institute of Technology
Research Article
Keywords: serious games, rehabilitation, hand, arm, telerehabilitation, stroke
Posted Date: June 7th, 2024
DOI: https://doi.org/10.21203/rs.3.rs-4438077/v1
License:   This work is licensed under a Creative Commons Attribution 4.0 International License. Read Full License
Additional Declarations: Competing interest reported. Alma Merians, Qinyin Qiu, Sergei Adamovich and Amanda Gross are inventors of NJIT - HoVRS. Qinyin
Qiu and Amanda Gross are founders and employees of NeuroTechR3, a company that is bringing R3THA, a subsequent iteration of NJIT HoVRS to market.

Abstract

Background: 

 

This parallel, randomized controlled trial examines intrinsic motivation, adherence and motor function improvement demonstrated by two groups of subjects that performed a twelve-week, home-based upper extremity rehabilitation program. Seventeen subjects played 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 to 80 years of age, at least six 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 system. Subjects had the Home Virtual Rehabilitation System [1]systems 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 twelve 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 Coecients. Classication and Regression Tree (CART) models were generated to predict responders using demographics and baseline measures.
 

Results: 

 

There were 5 dropouts and no adverse events. The main effect of time was statistically significant for four of the ve clinical outcome measures. There were no significant training group by time interactions. Measures of adherence did not differ between groups. 21 subjects from both groups, demonstrated clinically important improvements in UEFMA score of at least 4.25 points. Subjects with pretraining UEFMA scores below 53.5 averaged a seven-point UEFMA increase. IMI scores were stable pre to post training.
 

Conclusions: 

 

Scaffolding did not have a meaningful impact on adherence or motor function improvement. A sparsely supervised program of game-based treatment in the home was sufficient to elicit meaningful improvements in motor function and activities of daily living. Common factors considered barriers
to the utilization of telerehabilitation did not impact adherence or motor outcome.
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 comparable outcomes to 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 [9-11]. 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, 12-17]. Multiple factors have been identified as possible causes for varied adherence to technology supported rehabilitation interventions in the home [9, 18, 19]. Various authors have speculated that personal attributes such
as computer literacy, age and level of education, as well as socioeconomic factors such as employment status and income, might have an impact on the ability of persons with rehabilitation needs to accept and utilize technology based rehabilitation effectively [20, 21]. However, few studies have evaluated
these speculations. This study will evaluate the impact of personal and socioeconomic factors on 1) adherence to a technology supported rehabilitation program and 2) the ability to make motor function improvements after participating in a technology supported rehabilitation program. 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 to influence the frequency players pick up a game and play it, as well as the amount of time they play a game after initiating [22]. 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 [23]. This affords the participant immediate initial feelings of self-efficacy and then proceeds to challenge them.
Appropriate levels of challenge [24] and feelings of self-efficacy [25] are both associated with higher levels of motivation, as is the clear knowledge of results feedback [24] 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 will utilize a parallel randomized clinical trial to examine the adherence levels of subjects with stroke performing a twelve-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 [26, 27]. We compared these approaches to controlling game difficulty using 1) the Intrinsic Motivation Inventory to measure the impact of the two approaches on motivation, 2) system-collected
measurement of actual game play frequency and total training time to measure adherence and 3) clinical measures of upper extremity function to determine the effectiveness of the training programs. Our study 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 in an attempt to approximate a sparsely supervised rehabilitation program conducted by a therapist.