The online version of this article (doi:10.1186/s12984-017-0231-4) contains supplementary material, which is available to authorized users.
People with chronic arm impairment should exercise intensely to regain their abilities, but frequently lack motivation, leading to poor rehabilitation outcome. One promising way to increase motivation is through interpersonal rehabilitation games, which allow patients to compete or cooperate together with other people. However, such games have mainly been evaluated with unimpaired subjects, and little is known about how they affect motivation and exercise intensity in people with chronic arm impairment.
We designed four different arm rehabilitation games that are played by a person with arm impairment and their unimpaired friend, relative or occupational therapist. One is a competitive game (both people compete against each other), two are cooperative games (both people work together against the computer) and one is a single-player game (played only by the impaired person against the computer). The games were played by 29 participants with chronic arm impairment, of which 19 were accompanied by their friend or relative and 10 were accompanied by their occupational therapist. Each participant played all four games within a single session. Participants’ subjective experience was quantified using the Intrinsic Motivation Inventory questionnaire after each game, as well as a final questionnaire about game preferences. Their exercise intensity was quantified using wearable inertial sensors that measured hand velocity in each game.
Of the 29 impaired participants, 12 chose the competitive game as their favorite, 12 chose a cooperative game, and 5 preferred to exercise alone. Participants who chose the competitive game as their favorite showed increased motivation and exercise intensity in that game compared to other games. Participants who chose a cooperative game as their favorite also showed increased motivation in cooperative games, but not increased exercise intensity.
Since both motivation and intensity are positively correlated with rehabilitation outcome, competitive games have high potential to lead to functional improvement and increased quality of life for patients compared to conventional rehabilitation exercises. Cooperative games do not increase exercise intensity, but could still increase motivation of patients who do not enjoy competition. However, such games need to be tested in longer, multisession studies to determine whether the observed increases in motivation and exercise intensity persist over a longer period of time and whether they positively affect rehabilitation outcome.
The study is not a clinical trial. While human subjects are involved, they participate in a single-session evaluation of a rehabilitation game rather than a full rehabilitation intervention, and no health outcomes are examined.
Additional file 1: Raw data (questionnaire results and hand velocity) for all participants. (XLSX 24 kb)12984_2017_231_MOESM1_ESM.xlsx
Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, Ford E, Furie K, Go A, Greenlund K, et al. Heart disease and stroke statistics–2009 update: A report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009;119:e21. CrossRefPubMed
De Wit L, Putman K, Dejaeger E, Baert I, Berman P, Bogaerts K, Brinkmann N, Connell L, Feys H, Jenni W, Kaske C, Lesaffre E, Leys M, Lincoln N, Louckx F, Schuback B, Schupp W, Smith B, De Weerdt W. Use of time by stroke patients: a comparison of four European rehabilitation centers. Stroke. 2005;36:1977–83. CrossRefPubMed
Amirabdollahian F, Ates S, Basteris A, Cesario A, Buurke J, Hermens H, Hofs D, Johansson E, Mountain G, Nasr N, Nijenhuis S, Prange G, Rahman N, Sale P, Schätzlein F, van Schooten B, Stienen A. Design, development and deployment of a hand/wrist exoskeleton for home-based rehabilitation after stroke - SCRIPT project. Robotica. 2014;32:1331–46. CrossRef
Laver K, George S, Thomas S, Deutsch J, Crotty M. Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev. 2011;12:CD008349.
Colombo R, Pisano F, Mazzone A, Delconte C, Micera S, Carrozza MC, Dario P, Minuco G. Design strategies to improve patient motivation during robot-aided rehabilitation. J Neuroeng Rehabil. 2007;4. Article no. 3, http://jneuroengrehab.biomedcentral.com/articles/10.1186/1743-0003-4-3.
Mihelj M, Novak D, Milavec M, Ziherl J, Olenšek A, Munih M. Virtual rehabilitation environment using principles of intrinsic motivation and game design. Presence Teleop Virt. 2012;21:1–15. CrossRef
Alankus G, Lazar A, May M, Kelleher C. Towards customizable games for stroke rehabilitation. In: Proceedings of the 28th International Conference on Human Factors in Computing systems - CHI ’10. New York: ACM Press; 2010. p. 2113. CrossRef
Maclean N, Pound P, Wolfe C, Rudd A. Qualitative analysis of stroke patients’ motivation for rehabilitation. BMJ Br Med J. 2000;321:1051–4. CrossRef
Nijenhuis SM, Prange GB, Amirabdollahian F, Sale P, Infarinato F, Nasr N, Mountain G, Hermens HJ, Stienen AHA, Buurke JH, Rietman JS. Feasibility study into self-administered training at home using an arm and hand device with motivational gaming environment in chronic stroke. J Neuroeng Rehabil. 2015;12:89. CrossRefPubMedPubMedCentral
Weibel D, Wissmath B, Habegger S, Steiner Y, Groner R. Playing online games against computer- vs. human-controlled opponents: Effects on presence, flow, and enjoyment. Comput Hum Behav. 2008;24:2274–91. CrossRef
Lim S, Reeves B. Computer agents versus avatars: Responses to interactive game characters controlled by a computer or other player. Int J Hum Comput Stud. 2010;68:57–68. CrossRef
Johnson MJ, Feng X, Johnson LM, Ramachandran B, Winters JM, Kosasih JB. Robotic systems that rehabilitate as well as motivate: three strategies for motivating impaired arm use. In: Proceedings of the First IEEE/RAS-EMBS International Conference on Biomedical Robotics and Biomechatronics. Piscataway: IEEE; 2006. p. 254–9
Flores E, Tobon G, Cavallaro E, Cavallaro FI, Perry JC, Keller T. Improving patient motivation in game development for motor deficit rehabilitation. In: Proceedings of the 2008 International Conference in Advances on Computer Entertainment Technology. New York: ACM Press; 2008. p. 381.
Johnson MJ, Loureiro RCV, Harwin WS. Collaborative tele-rehabilitation and robot-mediated therapy for stroke rehabilitation at home or clinic. Intell Serv Robot. 2008;1:109–21. CrossRef
Ballester BR, Bermúdez i Badia S, Verschure PFMJ. Including social interaction in stroke VR-based motor rehabilitation enhances performance: a pilot study. Presence Teleop Virt. 2012;21:490–501. CrossRef
Novak D, Nagle A, Keller U, Riener R. Increasing motivation in robot-aided arm rehabilitation with competitive and cooperative gameplay. J Neuroeng Rehabil. 2014;11. Article no. 64, https://jneuroengrehab.biomedcentral.com/articles/10.1186/1743-0003-11-64.
Vanacken L, Notelaers S, Raymaekers C, Coninx K, van den Hoogen WM, IJsselsteijn WA, Feys P. Game-based collaborative training for arm rehabilitation of MS patients: a proof-of-concept game. In: Proceedings of GameDays. 2010. p. 2010.
Maier M, Ballester BR, Duarte E, Duff A, Verschure PFMJ. Social integration of stroke patients through the multiplayer Rehabilitation Gaming System. In: Proceedings of GameDays 2014. 2014. p. 100–14.
Goršič M, Novak D. Design and pilot evaluation of competitive and cooperative exercise games for arm rehabilitation at home. In: Proceedings of the 38th Annual International Conference of the IEEE Engineering in Medicine and Biology Society. Orlando: IEEE; 2016. p. 4690–4.
Beravs T, Reberšek P, Novak D, Podobnik J, Munih M. Development and validation of a wearable inertial measurement system for use with lower limb exoskeletons. In: 11th IEEE-RAS International Conference on Humanoid Robots. 2011. p. 212–7.
Weibel D, Wissmath B, Mast F. Immersion in mediated environments: the role of personality traits. Cyberpsychol Behav Soc Netw. 2010;13:251-56.
Fang X, Zhu M. Extraversion and computer game play: who plays what games? In: HCII ’11 Proceedings of the 14th International Conference on Human-Computer Interaction: Users and Applications. 2011. p. 659–67. CrossRef
Goldberg LR, Johnson JA, Eber HW, Hogan R, Ashton MC, Cloninger CR, Gough HG. The international personality item pool and the future of public-domain personality measures. J Res Pers. 2006;40:84–96. CrossRef
Tsurumi K, Itani T, Tachi N, Takanishi T, Suzumura H, Takeyama H. Estimation of energy expenditure during sedentary work with upper limb movement. J Occup Health. 2002;44:408–13. CrossRef
McCrea SM, Geršak G, Novak D. Absolute and relative user perception of classification accuracy in an affective videogame. Interact Comput. 2017;29:271–86.
Caurin GAP, Siqueira AAG, Andrade KO, Joaquim RC, Krebs HI. Adaptive strategy for multi-user robotic rehabilitation games. In: Proceedings of the 2011 Annual International Conference of the IEEE Engineering in Medicine and Biology Society. 2011. p. 1395–8. CrossRef
Andrade K, Martins J, Caurin GAP, Joaquim RC, Fernandes G. Relative performance analysis for robot rehabilitation procedure with two simultaneous users. In: Proceedings of the 4th IEEE RAS & EMBS International Conference on Biomedical Robotics and Biomechatronics. Piscataway: Ieee; 2012. p. 1530–4
Zimmerli L, Krewer C, Gassert R, Müller F, Riener R, Lünenburger L. Validation of a mechanism to balance exercise difficulty in robot-assisted upper-extremity rehabilitation after stroke. J Neuroeng Rehabil. 2012;9. Article no. 6, https://jneuroengrehab.biomedcentral.com/articles/10.1186/1743-0003-9-6.
Mace M, Rinne P, Kinany N, Bentley P, Burdet E: Collaborative gaming to enhance patient performance during virtual therapy. In 3rd International Conference on NeuroRehabilitation. Segovia, Spain; 2016:accepted for publication.
Ganesh G, Takagi A, Osu R, Yoshioka T, Kawato M, Burdet E. Two is better than one: Physical interactions improve motor performance in humans. Sci Rep. 2014;4. Article no. 3824, http://www.nature.com/articles/srep03824.
Lanini J, Tsuji T, Wolf P, Riener R, Novak D. Teleoperation of two six-degree-of-freedom arm rehabilitation exoskeletons. In: 2015 IEEE International Conference on Rehabilitation Robotics. 2015.
Noohi E, Zefran M. Quantitative measures of cooperation for a dyadic physical interaction task. In: Proceedings of the 14th IEEE-RAS International Conference on Humanoid Robots (Humanoids). 2014. p. 469–74.
Trlep M, Mihelj M, Puh U, Munih M. Rehabilitation robot with patient-cooperative control for bimanual training of hemiparetic subjects. Adv Robot. 2011;25:1949–68. CrossRef
Nagle A, Novak D, Wolf P, Riener R. Increased enjoyment using a tablet-based serious game with regularly changing visual elements: A pilot study. Gerontechnology. 2015;14:32–44. CrossRef
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