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To cite this article: Ayhan Aşkın, Emel Atar, Hikmet Koçyiğit & Aliye Tosun (2018): Effects of
Kinect-based virtual reality game training on upper extremity motor recovery in chronic stroke,
Somatosensory & Motor Research, DOI: 10.1080/08990220.2018.1444599
ORIGINAL ARTICLE
CONTACT Ayhan Aşkın ayhanaskin@hotmail.com Physical Medicine and Rehabilitation, Izmir Katip Celebi University, Izmir 35620, Turkey
ß 2018 Informa UK Limited, trading as Taylor & Francis Group
2 A. AŞKIN ET AL.
Materials and methods Good View Hunting: The participant is asked to delete the
Participants dirty spots in different regions of the screen or to clean a
water stain, fog, kid’s drawing or car dust using his or her
Forty chronic stroke patients (mean ages: 55.1 ± 10.2 years; affected extremity. A high score can be obtained by mov-
range 34–72 years; 28 males, 12 females) with upper limb ing fast. The patients usually performed the active move-
paresis who met the following inclusion criteria were ments of shoulder and elbow on the affected side in this
included in the study: (1) ischemic or hemorrhagic stroke; (2) game part.
adults (>18 years old); (3) stroke onset >6 months; (4) Hong Kong Chef: It consists of two sections. Hong Kong
absence of cognitive, visual impairment or neglect that made Egg Tart and BBQ Pork with Rice. The aim of both sec-
it impossible to follow the instructions during treatment ses- tions is to achieve the stages of making the food (drag-
sions; and (5) voluntary shoulder, elbow, and wrist movement ging and dropping ingredients, mixing, cutting and
that can perform game commands. Two patients were lost to cooking). Patients are required to be as fast as possible. A
follow-up and the study was completed with 38 patients high score can be obtained by moving fast. Particularly
(mean ages: 55.0 ± 10.4 years; range 34–72 years; 27 males, 11 active shoulder, elbow, and wrist movements are per-
females). Patients were excluded if they were clinically formed in this game part. The Kinect game system and
unstable or had concomitant neurodegenerative disorders, the position of the patient are shown in Figure 1.
other intracranial diseases, history of seizure, significant med-
ical or psychiatric illness, fixed contractures or bony deform- Before the treatment sessions, demonstrations about the
ities of the affected extremity, taking any drug that could games were made by an experienced doctor. In all sessions,
affect balance, and severe cognitive problems (Mini-mental the patients played games under the supervision of the same
test score of <20/30). trained medical staff. Patients were allowed to play all three
Demographic data of the patients (age, gender, educa- game parts for 1 hour, respectively. The highest scores for
tional status, body mass index), time since stroke, affected each of the three game parts were recorded before and
extremity, types of stroke, and comorbidities were recorded. after treatment.
Participants were informed about the study and provided
written informed consents. The protocol was performed in
Physical therapy
accordance with the ethical standards laid down in the 1964
Declaration of Helsinki and approved by the local Research All the participants received the same standardized PT proto-
Ethics Committee (Approval number: 03.06.2015/103). cols in neurological rehabilitation. The PT program included
SOMATOSENSORY & MOTOR RESEARCH 3
Table 2. Baseline/post-intervention comparisons in outcome measures within and between the groups.
Group A (n ¼ 18) Group B (n ¼ 20)
PT þ Kinect PT
Baseline Post-intervention Baseline Post-intervention p1 p2 p3
MAS
Proximal 1.0 (0.0–3.0) 1.0 (0.0–2.0) 1.5 (0.0–3.0) 1.0 (0.0–3.0) 0.063 0.025* 0.157
Distal 1.0 (0.0–3.0) 1.0 (0.0–3.0) 1.0 (0.0–4.0) 1.0 (0.0–4.0) 0.059 0.157 0.317
Hand 1.0 (0.0–3.0) 1.0 (0.0–3.0) 2.0 (0.0–4.0) 1.0 (0.0–4.0) 0.076 0.157 0.564
Brunnstrom Stages
UE 3.0 (2.0–4.0) 4.0 (2.0–4.0) 3.0 (1.0–5.0) 3.0 (1.0–5.0) 0.900 0.046* 0.317
Hand 3.0 (2.0–4.0) 3.0 (2.0–4.0) 3.0 (1.0–5.0) 3.0 (1.0–5.0) 0.242 0.157 0.999
Fugl-Meyer Assessment 39.0 (22.0–56.0) 42.0 (23.0–58.0) 30.5 (19.0–58.0) 31.5 (19.0–58.0) 0.319 <0.001* 0.034*
Box and Block test 4.0 (0.0–64.0) 5.0 (0.0–69.0) 0.5 (0.0–39.0) 1.0 (0.0–38.0) 0.668 0.044* 0.014*
Motricity index 40.0 (20.0–77.0) 55.5 (23.0–93.0) 37.5 (23.0–30.0) 40.0 (23.0–73.0) 0.369 0.001* 0.006*
Kinect VR game scores
Good View Hunting 1270.0 (760.0–1610.0) 1565.0 (910.0–1980.0) – – – <0.001* –
Hong Kong Egg Tart 46.0 (19.0–64.0) 64.0 (41.0–88.0) – – – <0.001* –
BBQ Pork with Rice 35.0 (9.0–54.0) 55.5 (17.0–89.0) – – – <0.001* –
Values are median (minimum–maximum). Statistically significant (p < 0.05).
MAS: Modified Ashworth Scale; PT: physical therapy; UE: upper extremity; VR: virtual reality.
Statistical analysis: p1, baseline comparison between the groups (Mann–Whitney U-test); p2, baseline and post-intervention comparison within group A (Wilcoxon
test); p3, baseline and post-intervention comparison within group B (Wilcoxon test).
control group. In addition, FMA, BBT, MI scores, and AROM (Pollock et al. 2014). Kinect-based VR training is a novel tech-
(shoulder flexion–abduction–external rotation and elbow nology which is increasingly being used in neurorehabilita-
extension) were significantly increased in both groups, how- tion to modulate rehabilitation sessions (Laver et al. 2017).
ever, these changes were greater in the Kinect-based VR Many VR systems, often generic (i.e., not developed for
group except for BBT score and AROM (adduction of shoul- rehabilitation purposes) commercial computer games, are
der and extension of elbow). Although both groups bene- used to perform a series of exercises (Sin and Lee 2013;
fited from rehabilitative procedures to some extent, Kinect- Saposnik et al. 2016). These systems provide a non-immersive
based VR training seemed to contribute more to the environment that is fun and extrinsically motivating for
improvement of motor function and AROM of affected upper patients (Park et al. 2017). And also, VR-based training is able
limbs in chronic stroke patients. to provide high rehabilitation doses, both in terms of active
Neurological reorganization plays an important role in the training time and repetitions per session. In our study,
restoration of UE functions. It can extend for a much longer patients received a total of 1 hour/day of active VR-based
period of time and is of particular interest because it can be training of the UE, with a total duration of the training ses-
influenced by rehabilitation training (Hebert et al. 2016). sions of 20 hours (including breaks and time between
There is strong evidence suggesting that a high dose of games). We think that this training duration—compatible
repetitive task practice can improve recovery. Thus, increas- with other studies in the literature—is enough to accept the
ing therapy dose, also in the chronic phase of the disease, treatment as high-dose repetitive intensive rehabilitation
might be a critical factor to achieve a better outcome (Perez-Marcos et al. 2017).
6 A. AŞKIN ET AL.
Table 3. Comparison of differences from baseline between the groups. results also revealed significant improvements in FMA, MI,
Differences from baseline and AROM (except adduction of shoulder and extension of
Group A (n ¼ 18) Group B (n ¼ 20) elbow) in the Kinect-based training group when compared
PT þ Kinect PT p with the control group. However, we failed to find any sig-
Modified Ashworth Scale nificant difference in BBT scores in-between. Since the VR
Proximal 0.0 (1.0–0.0) 0.0 (2.0–1.0) 0.494 game selected in our study did not include training specific-
Distal 0.0 (1.0–0.0) 0.0 (1.0–0.0) 0.491
Hand 0.0 (1.0–0.0) 0.0 (1.0–1.0) 0.618 ally for manual dexterity, other games specifically designed
Brunnstrom Stages for manual dexterity can be added to the VR rehabilitation
UE 0.0 (0.0–1.0) 0.0 (0.0–1.0) 0.122 program for this purpose.
Hand 0.0 (0.0–1.0) 0.0 (0.0–0.0) 0.131
Fugl-Meyer Assessment 2.0 (1.0–10.0) 0.0 (0.0–2.0) <0.001* On the contrary, Adie et al. (2017) recently investigated
Box and Block test 0.5 (3.0–7.0) 0.0 (1.0–3.0) 0.744 the efficacy of using Nintendo Wii Sports to improve affected
Motricity index 6.0 (0.0–17.0) 0.0 (0.0–6.0) 0.019* arm function after stroke and concluded that the Wii was not
Active range of motion
Shoulder superior to arm exercises in home-based rehabilitation
Flexion 20.0 (0.0–40.0) 0.0 (0.0–10.0) <0.001* although it was more expensive than arm exercises. Similarly,
Extension 5.0 (0.0–30.0) 0.0 (0.0–10.0) 0.035* Kong et al. (2016) revealed that 12 sessions of augmented
Abduction 20.0 (10.0–30.0) 0.0 (0.0–10.0) <0.001*
Adduction 0.0 (0.0–10.0) 0.0 (0.0–10.0) 0.131 upper limb exercises via Wii gaming or conventional therapy
Internal rotation 5.0 (0.0–25.0) 0.0 (0.0–10.0) 0.005* over a 3-week period was not effective in enhancing upper
External rotation 10.0 (0.0–20.0) 0.0 (0.0–10.0) 0.002* limb motor recovery compared to controls. We assume that
Elbow
Flexion 0.0 (0.0–15.0) 0.0 (0.0–10.0) 0.040* differences in the design of the studies, sample sizes, and
Extension 0.0 (0.0–20.0) 0.0 (0.0–10.0) 0.637 gaming systems might have possibly caused these contra-
Wrist dictory results. The game used in this study is not commer-
Flexion 5.0 (0.0–20.0) 0.0 (0.0–10.0) 0.009*
Extension 0.0 (0.0–30.0) 0.0 (0.0–10.0) 0.022* cial, but has been developed by a research team of Hong
Values are median (minimum–maximum). Statistically significant (p < 0.05). Kong Polytechnic University specifically for stroke patients.
PT: physical therapy; UE: upper extremity. Therefore, significant improvements in most of the clinical
Statistical analysis: Mann–Whitney U-test. outcome measures superior to conventional rehabilitation
could be achieved. There is no other study in the literature
Recent studies revealed that the Kinect-based VR gaming that uses our Kinect-based VR gaming system, but our results
system is an effective therapeutic approach for improving are similar to the current data (Laver et al. 2017).
motor function during stroke rehabilitation. Sin and Lee Patients sometimes report low levels of fatigue and stress
(2013) evaluated the effects of additional VR training using generated during the rehabilitation training sessions. In a
Xbox Kinect on UE function (including AROM, FMA, and BBT) recent study that used Wii games for UE training in subacute
in stroke patients and found that there were significant dif- stroke, participants reported adverse events such as numb-
ferences between the two groups at follow-up for AROM ness, dizziness, pins and needles, headaches, or nausea
(flexion, extension, abduction of the shoulder and flexion of (Saposnik et al. 2016). However, no adverse event was
the elbow but not for AROM of the wrist), FMA score, and reported in our study. This, also, is very likely because our
BBT score. They finally concluded that VR training using Xbox Kinect-based VR exercises were specifically designed for
Kinect can improve the functioning of the UE. Park et al. stroke rehabilitation purposes by clinicians, and were vali-
(2017) investigated the effects of VR training, using the Xbox dated with stroke patients before (Tong 2014).
Kinect-based game system, on the motor recovery of patients There are several limitations of our study. First is the rela-
with chronic hemiplegic stroke and found significant tively small sample size and the absence of a sham group to
improvements for the Berg Balance Scale, the Timed Up and estimate the natural recovery of stroke. Second, the improve-
Go test, and the 10-meter Walk Test (but not for FMA scores) ments observed in the Kinect-based VR group may have
for the intervention group. It was reported that the use of been affected by the total intervention time (1 hour more
additional VR training with the Xbox Kinect gaming system is than the PT group). Third, due to our strict inclusion criteria
an effective therapeutic approach for improving motor func- and diversity of cerebrovascular diseases, the results of this
tion during stroke rehabilitation. Similarly, Fan et al. (2014) study may not be generalized to patients with stroke. Fourth,
revealed that VR gaming has immediate effects on motor due to the short duration of the study, we are unable to con-
recovery and provides motivation for treatment compliance clude on the long-term effect of VR-based training therapy
in stroke patients. Choi et al. (2014) suggested that the com- on UE motor function. One of the strengths of our study is
mercial gaming-based VR therapy was as effective as conven- that our VR-based gaming programs were designed for
tional occupational therapy on the recovery of UE motor and stroke patients. Therefore, we did not need intense supervi-
daily living function in subacute stroke patients. Manlapaz sion of medical staff to optimize VR training. Further studies
et al. (2010) determined that the use of Nintendo Wii pro- including a larger number of subjects with long-term follow-
vided marked improvement in the UE function of chronic up assessments are needed to interpret the results
stroke patients demonstrated within 6 weeks. Both Saposnik more accurately.
et al. (2010) and Lee et al. (2016) reported that VR technol- To conclude, our results suggest that the adjunct use of
ogy represents a safe, feasible, and potentially effective alter- Kinect-based VR training may contribute to the improvement
native to facilitate rehabilitation therapy and promote motor of UE motor function and AROM in chronic stroke patients.
recovery after stroke. Consistent with these findings, our Further studies with a larger number of subjects with longer
SOMATOSENSORY & MOTOR RESEARCH 7
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Ayhan Aşkın http://orcid.org/0000-0001-9445-4430
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Emel Atar http://orcid.org/0000-0002-8373-1196
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