Final Report Summary - VR STROKE REHAB (Virtual Reality Intervention for Stroke Rehabilitation) In the 'VR Stroke Rehab' study I have demonstrated that video-game consoles, not developed specifically for rehabilitation, can be successfully used to provide a motivating intervention for individuals with chronic stroke to maintain their functional level, prevent deterioration, facilitate physical activity, facilitate movement and improve health-related quality of life. Stroke is defined as a clinical syndrome with rapidly developing clinical signs of focal or global disturbances of cerebral function, lasting for more than 24 hours or leading to death with no apparent cause other than of vascular origin. In Israel there are approximately 16,000 new cases of stroke per year and recently stroke has been recognized by the Israeli health-care policy planners as a top priority disease. The most common symptom following stroke is weakness or paralysis of the arm and leg, contralateral to the side of brain lesion. Additional symptoms include sensory, perceptual, cognitive and meta-cognitive deficits which all result in a decreased ability to perform activities of daily living such as dressing, shopping and cooking. Therefore these individuals need to continue to be active in order to maintain their functional level, prevent deterioration and facilitate improvement. Regular physical activity has been recognized as one of the most important health behaviors that decreases the risk of a recurrent stroke. However, recent findings suggest that people with stroke following their rehabilitation do not perform enough physical activity and movement with their upper and lower extremities. To meet this challenge I performed the following:1. Developed a protocol for using video-games in a small group setting (stage I of the study) and for self-training at home (stage II of the study). 2. Quantified and classified the movements of individuals with stroke while playing video-games and compared it to movements that are produced during traditional therapy. 3. Conducted two randomized controlled trials utilizing video-games; Clinical randomized controlled trials provide the highest level of research evidence. Stage I: Using video-games in a small group setting Objectives: 1) To investigate the feasibility of using video-games in a group setting and 2) to compare the effectiveness of video-games for a group intervention to a traditional group intervention for improving physical activity in individuals with chronic stroke. Design: A single-blind randomized controlled trial with evaluations pre and post a 3-month intervention, and at 3-month follow-up. Compliance (session attendance), satisfaction and adverse effects were feasibility measures. Grip strength and gait speed were measures of physical activity. Hip accelerometers quantified steps/day and the Action Research Arm Test was used to assess the functional ability of the weaker upper extremity. Results: Forty-seven community-dwelling individuals with chronic stroke (29-78 years) were randomly allocated to receive video-games (N=24) or traditional therapy (N=23) in a group setting. There was high treatment compliance for both interventions (video-games-78%, traditional therapy-66%), but satisfaction was rated higher for the video-games (93%) than the traditional therapy (71%) (2=4.98 p=0.026). Adverse effects were not reported in either group. In both groups significant improvements were demonstrated for gait speed (F=3.9 p=0.02) grip strength of the weaker (F=6.67 p=0.002) and stronger hands (F=7.5 p=0.001). Daily steps and functional ability of the weaker hand did not increase in either group. Conclusions: Using video-games in a small group setting is feasible, safe and satisfying. Video-games improve indicators of physical activity of individuals with chronic stroke. These finding were presented at national and international conferences. Stage II: Using video-games for self-training at home Objectives: The feasibility of using video-games for self-training of the upper extremity and balance following stroke was assessed. Specifically we aimed to compare the (1) training time, (2) satisfaction and (3) effectiveness of a self-training program using video-games compared to a traditional self-training program. Design: A single-blind randomized controlled trial with four assessments; two before and two following the 5-week self training intervention was conducted by an assessor who was blind to the treatment allocation. The self-training intervention included playing video-games or performing traditional exercises for one hour a day, 5 times a week for 5 weeks. An occupational therapist conducted two home visits during this time; an initial training session and a follow-up supervision session. Results: To date 24 participants with chronic stroke have been recruited into the study and 18 participants (7 men, 5 women, 33-67 years) have completed the intervention (N=9 video-games, N=9 traditional therapy). High levels of compliance (4.4-6.0 hours of weekly practice) and satisfaction with the intervention were found for both groups. Significantly higher perceived exertion was reported (z=-2.1 p< 0.03) for playing the video-games while standing which also significantly improved standing balance. An overall improvement in upper extremity measures was seen for both groups. Conclusions: These preliminary findings are encouraging since it provides a potential avenue to provide on-going activity for individuals with chronic stroke to maintain their functional level. 4. Performed two qualitative studies following each stage to learn about the experiences and perceptions of individuals with chronic stroke who experienced video-games and therapists who used the video-games Background: Video-games have become popular in rehabilitation. Understanding how participants with stroke and therapists perceive the use of video-games in stroke rehabilitation might assist in the development of future treatment protocols. In this mixed method study we aimed to learn about the experiences and perceptions of 1) individuals with chronic stroke who experienced video-games in a small group and 2) therapists who provided the video-games intervention. Methods: Twenty individuals with chronic stroke completed a 3-month (2-one hour sessions per week) video-games intervention. A subgroup of eight participants (4 men and 4 women) aged 29-69 [mean age (SD) 51.88 (12.07)] was interviewed and a focus group of the 3 therapists took place following the intervention. Satisfaction questionnaires were filled in, semi-structured interviews and focus group were conducted, audio-taped, transcribed verbatim and analyzed using content analysis. Results: Ninety-three percent of the 20 participants enjoyed the intervention "very much/extremely". Three main categories derived from the eight participants and therapists: Characteristics of the video-games, Emotional experience and Intervention outcomes (for participants) / Professional insights (for therapists). The use of video-games as an intervention tool for ongoing stroke rehabilitation seems to be embraced by both participants and therapists as a motivating tool to facilitate whole-body movement. Conclusions: The use of video-games for a small group of participants increased the fun, competition and motivation of these participants. Working in a team was important for increasing therapist's satisfaction.
