Virtual Reality Gaming for Individuals With Chronic Stroke

BACKGROUND AND PURPOSE: In the United States, stroke is one of the leading causes of long-term disability, costing billions of dollars in health care services. Approximately 50% of individuals with stroke cannot use their affected upper extremity (UE) functionally, and loss of arm function is a major concern even years after the first stroke onset.

Virtual reality (VR) gaming is an emerging area in practice. Because VR gaming provides instant visual and auditory feedback based on user performance and offers high repetition and task-oriented movements, it might be beneficial for UE motor recovery in patients with stroke. Especially in the chronic stage, when many interventions are not covered by insurance, using a commercially available VR gaming system such as Xbox Kinect (Microsoft, Redmond, WA) at home, with appropriate monitoring, might be a promising approach for UE rehabilitation.

The purpose of this study was to investigate the effect of combining telehealth and VR gaming for individuals with chronic stroke. Our research questions were, Does Xbox Kinect video gaming improve UE function and health-related quality of life (QOL) for individuals with chronic stroke? and What are the experiences of individuals with chronic stroke who participate in a home-based Xbox Kinect VR intervention?

METHOD: In this pilot study, we used a mixed methods case study design. Two participants were recruited through local stroke support groups and flyers distributed throughout the community and social media. Inclusion criteria were as follows: diagnosis of stroke >6 mo previously, Mini-Mental State Examination score ≥24, ability to read and speak English, and working television at home. Exclusion criteria included <25% shoulder range of motion across all planes of movement, history of seizures, and current participation in other interventions for UE movements.

The Xbox Kinect was installed in each participant’s home. Instruction was provided during the installation. During the intervention, participants were assigned games to play for 30 min/session, 4 days/wk, for 4 wk. We maintained contact with the participants using a telerehabilitation approach 2×/wk.

We administered the following instruments at baseline and postintervention: the Wolf Motor Function Test (WMFT), the Fugl-Meyer Assessment–Upper Extremity (FMA–UE), and the Modified Ashworth Scale to measure UE motor ability and function and the Stroke Impact Scale (SIS) to assess health-related QOL. Descriptive statistics were used to summarize the data. We also conducted one-on-one semistructured interviews after the intervention to understand participants’ experiences with this VR home program.

RESULTS: Quantitative data revealed a positive change in UE movement and function. Both participants’ overall score increased by 4 points on the FMA–UE and >7 points on the WMFT. One participant showed an increased SIS score, while the other’s SIS score stayed the same. Qualitative data revealed that participants viewed the intervention as a leisure activity and were motivated to do it. Additionally, they liked the flexibility and telehealth approach. Although they perceived improvement, they also reported experiencing frustration with the technology sometimes.

CONCLUSION: Using commercial VR gaming with telehealth offers a promising, economical, and effective intervention. Participants were engaged, liked the flexible schedule, and showed functional improvement. The effect of this approach should be examined using a randomized controlled trial with a larger sample.

IMPACT STATEMENT: Our study showed potential benefit of using technology (VR and telehealth) to deliver extended treatment to clients in the chronic stage of stroke. VR gaming providing high intensity of repetition might also be an effective supplemental intervention for patients in the subacute or acute stage of stroke. As technology advances and is increasingly available to the general public, occupational therapy practitioners should consider incorporating easy access technology into intervention to maximize patients’ outcomes.

References

Merians, A. S., Poizner, H., Boian, R., Burdea, G., & Adamovich, S. (2006). Sensorimotor training in a virtual reality environment: Does it improve functional recovery poststroke? Neurorehabilitation and Neural Repair, 20, 252–267. https://doi.org/10.1177/1545968306286914

Saposnik, G., Teasell, R., Mamdani, M., Hall, J., McIlroy, W., Cheung, D., . . . Bayley, M. (2010). Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: A pilot randomized clinical trial and proof of principle. Stroke, 41, 1477–1484. https://doi.org/10.1161/STROKEAHA.110.584979

Subramanian, S. K., Lourenco, C. B., Chilingaryan, G., Sveistrup, H., & Levin, M. F. (2013). Arm motor recovery using a virtual reality intervention in chronic stroke: Randomized control trial. Neurorehabilitation and Neural Repair, 27, 13–23. https://doi.org/10.1177/1545968312449695