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Game-Based Telerehabilitation on Motor Function in Stroke Patients
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Kimia Moradiani1    , Vahideh Moradi2 , Gholamreza Hassanzadeh3 , Hamid Reza Asgari4 , Ardalan Shariat *5 |
1- M.Sc in Orthotics and Prosthetics.
2- Assistant Professor of Orthotics and Prosthetics, Iran-Helal Institute of Applied Science and Technology, Tehran, Iran. Research Center for Health Management in Mass Gathering, Tehran, Iran.
3- Professor of Anatomical Sciences, Department of Anatomy, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. Department of Neuroscience and Addiction Studies, School of Advanced Technologies in Medicine, Tehran University of Medical Sciences, Tehran, Iran. Department of Digital Health, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran.
4- Associate Professor of Anatomical Sciences, Department of Anatomy, School of Medicine Iran University of Medical Sciences, Tehran, Iran.
5- Assistant Professor of Telehealth, Department of Digital Health, School of Medicine, Tehran University of Medical Sciences, Tehran, Iran. , ardalansh2002@gmail.com |
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Keywords: Telemedicine [MeSH], Telerehabilitation [MeSH], Stroke [MeSH], Gamification [MeSH]
Article ID: Vol27-11 |
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Type of Study: Review Article |
Subject:
Health System
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Abstract: (40 Views) |
Extended Abstract
Introduction
Stroke is the second leading cause of death and the third leading cause of both disability and death combined globally. In recent decades, the incidence, prevalence, mortality, and disability associated with stroke have continuously increased, particularly in low-income countries. In Iran, this condition is on the rise, affecting 372 individuals per 100,000 population. Premature deaths and disabilities resulting from stroke have led to reduced productivity and increased social costs within the country. Almost all stroke survivors experience complications such as sensory impairments and limb paralysis, followed by reduced muscle strength and limb inability to move freely. Ultimately, these complications lead to a decreased ability to self-care and a reduced quality of life for these patients. A variety of pharmacological and non-pharmacological treatments, employing multidisciplinary approaches, are utilized for managing chronic post-stroke disorders. These treatments include rehabilitation-based interventions, such as exercise therapy, orthotic therapy, shockwave therapy, and brain stimulation. However, consistently providing these treatments with sufficient intensity and appropriate continuity has always been a challenge for healthcare systems due to their limited capacities. The coronavirus disease 2019 (COVID-19) pandemic, given the high risk of infection for neurological patients, culminated in a significant transformation in neurological care.
Telerehabilitation is a dynamic and growing subfield of telemedicine that enables the remote delivery of comprehensive rehabilitation services and can be particularly valuable in low-income countries. Telerehabilitation offers a suitable alternative to traditional post-stroke rehabilitation treatments, especially in remote areas. It also leads to time and cost savings for the patient, their family, and the healthcare system. Continuity in practice is of significant importance in neurorehabilitation. The ability to perform treatment in the patient's home enhances the quality and continuity of care, thereby positively impacting the patient's quality of life and functional outcomes. Novel approaches in telerehabilitation, based on new and evolving technologies, can transform repetitive treatments into a more engaging experience for the patient. Game-based rehabilitation approaches in the homes of stroke patients can potentially increase patient motivation for regular participation in treatment sessions and culminate in improved motor function in these patients. Given the increase in clinical studies employing a telerehabilitation approach following the COVID-19 pandemic, the present study was conducted to evaluate game-based telerehabilitation on motor function in stroke patients.
Methods
In this narrative review, English keywords "Game," "Games," "Serious games," "Telerehabilitation," and "Stroke" were searched in the PubMed database using the AND operator between them, up to August 2024. A total of 118 articles were initially found. After removing duplicates and articles published before 2018, the number was reduced to 76 and then 59, respectively. Subsequently, the titles and abstracts of the remaining 59 articles were screened based on the study's inclusion and exclusion criteria, leading to the selection of 26 articles for full-text review according to these criteria. To minimize the potential for selection bias, the article review was conducted independently by two researchers who were blinded to each other's selections. Ultimately, 9 articles were included in the study after the aforementioned reviews. The articles were then evaluated concerning participant demographics and number, intervention design and type, intervention duration, parameter type, the outcomes of the intervention on limb movement improvement, and study limitations.
Discussion
The reviewed articles comprised 9 studies published from 2019 to 2022. In addition to examining the effects of interventions on improving motor function in stroke patients, these articles also investigated other parameters, such as motivation and treatment adherence, cognitive and emotional function, technology acceptance rate, intervention feasibility, and quality of life. However, given the objective of this study, which focuses on the effect of game-based telerehabilitation on motor function improvement in stroke patients, the results pertaining to these other parameters were not analyzed. Eight of the reviewed studies were conducted remotely in patients' homes. A study was conducted in a simulated telerehabilitation environment within a treatment center. It was included in this study due to its proper execution and investigation of balance, a factor not addressed in other studies. The intervention design in the conducted studies was based on the use of technologies, such as virtual reality, cameras, controllers, and internet-based communication tools. The studies exhibited considerable differences in their design, including the presence or absence of a control group, the type of comparative groups, the duration of each intervention session, the overall intervention duration, the design of the games, the type of therapist supervision, and the number of participants. Of the 9 studies reviewed, 6 focused on improving upper limb motor function, 2 on improving lower limb motor function, and 1 on improving motor function in both upper and lower limbs. In 2019, Fluet et al. investigated the effect of interactive telerehabilitation games on upper limb motor function in 11 individuals with unilateral stroke complications using the Fugl–Meyer Assessment of the Upper Extremity (FMA-UE) and the Box and Block Test (BBT), reporting a positive effect. In 2020, Burdea et al. investigated 8 patients, utilizing the FMA-UE, the Active Range of Motion (AROM) test measured with a goniometer, the Chedoke Arm and Hand Activity Inventory (CAHAI), the Jebsen-Taylor Hand Function Test (JHFT), the Grip and Pinch Strength Test measured with a dynamometer and pinchmeter, the Shoulder Strength Test measured with graded weights, and the Upper Extremity Functional Index (UEFI). Cramer et al. also examined 13 patients using the FMA-UE and the BBT. In addition, Qiu et al. assessed 15 patients using the FMA-UE and reported positive effects of game-based telerehabilitation on improving upper extremity motor function. Cramer et al. also evaluated the effect of this intervention on the lower extremity using the Lower Extremity Fugl-Meyer (LE-FM) scale and by assessing gait speed, deeming its effect positive. In 2021, Chen et al. reported that a game-based telerehabilitation system improved the balance of 30 patients, using the Berg Balance Scale (BBS), the Timed Up and Go (TUG) test, the Modified Falls Efficacy Scale (MFES), the Motor Index (MI) scale, and the Functional Ambulation Categories (FAC). They found its efficacy to be equivalent to or better than traditional rehabilitation systems. In 2022, Allegue et al. investigated 11 patients, comparing the effects of game-based telerehabilitation with traditional home-based exercise rehabilitation. They demonstrated an improvement in upper extremity motor function in both groups using the FMA-UE, the Motor Activity Log (MAL) scale, and the Stroke Impact Scale (SIS). Moreover, in the same year, in another study investigating 51 patients using the FMA-UE, the MAL, and the SIS, Hernandez et al. reported an improvement in several parameters affecting upper extremity function in both the game-based telerehabilitation group and the home exercise program-based rehabilitation group. They further stated that there was no significant difference in this improvement between the two groups. Again, in the same year, Lim et al. explored the effect of game-based telerehabilitation on improving lower extremity motor function and gait in three patients using the Functional Gait Assessment (FGA) tools and gait speed analysis, reporting gait improvement. In another study, Gauthier et al. examined and compared 167 patients across four different intervention groups using the MAL tool and reported a greater clinical improvement in the upper extremity in the game-based telerehabilitation group with and without therapist supervision, compared to traditional rehabilitation.
According to the conducted studies, game-based telerehabilitation can have a positive effect on motor function in stroke patients. However, these studies exhibited limited generalizability, necessitating future research with larger and more diverse sample sizes in terms of age, gender, race, level of post-stroke disability, literacy level, and geographical location.
Ethical Statement
This study received approval from the Research Ethics Committee at the Faculty of Medicine, Tehran University of Medical Sciences (IR.TUMS.MEDICINE.REC.1403.277).
Funding
This study received no institutional funding.
Authors' Contributions
Kimia Moradiani: Project execution, data collection, data analysis, drafting of the initial manuscript, and approval of the final manuscript.
Vahideh Moradi: Project administration and design, project execution, data collection, drafting of the initial manuscript, and approval of the final manuscript.
Gholamreza Hassanzadeh: Project administration and design, interpretation of results, drafting of the initial manuscript, and approval of the final manuscript.
Hamid Reza Asgari: Project execution and data collection.
Ardalan Shariat: Project administration and design, project execution, data analysis, interpretation of results, drafting of the initial manuscript, and approval of the final manuscript.
Conflicts of Interest
No conflicts of interest.
Acknowledgments
We would like to thank all colleagues and individuals who supported us in conducting this study.
Key Message: Given the reported positive outcomes of game-based telerehabilitation approaches on motor function of stroke patients, there is a clear need in our country for the design of games that are culturally and linguistically appropriate. These games should require minimal advanced equipment and be easy to use, enabling post-stroke rehabilitation to reach the remotest parts of the country at a reasonable cost, thereby increasing patient access to treatment.
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