This research was supported by grant no. 06-2013-105 from the SK Telecom Research Fund. This work was supported by the Soonchunhyang University Research Fund.

The study was approved by the Seoul National University Bundang Hospital Institutional Review Board, and all participants gave written informed consent before screening.
1. Game Contents Development
NOTE: The mobile game-based upper extremity virtual reality program for patients with stroke (MoU-Rehab) consists of mobile game applications.
<ol>
	<li>Install the studio and environment for development using a programing language.</li>
	<li>Collect data on x, y and z...

<ol>
	<li>Segal, M. E., Whyte, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Modeling+case+mix+adjustment+of+stroke+rehabilitation+outcomes.">Modeling case mix adjustment of stroke rehabilitation outcomes.</a> American journal of physical medicine &amp; rehabilitation. 76 (2), 154-161 (1997).</li><li>Gresham, G. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Residual+disability+in+survivors+of+stroke--the+Framingham+study.">Residual disability in survivors of stroke--the Framingham study.</a> N Engl J Med. 293 (19), 954-956 (1975).</li><li>Taub, E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Technique+to+improve+chronic+motor+deficit+after+stroke.">Technique to improve chronic motor deficit after stroke.</a> Arch Phys Med Rehabil. 74 (4), 347-354 (1993).</li><li>Richards, L., Pohl, P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Therapeutic+interventions+to+improve+upper+extremity+recovery+and+function.">Therapeutic interventions to improve upper extremity recovery and function.</a> Clin Geriatr Med. 15 (4), 819-832 (1999).</li><li>Arya, K. N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meaningful+task-specific+training+(MTST)+for+stroke+rehabilitation:+a+randomized+controlled+trial.">Meaningful task-specific training (MTST) for stroke rehabilitation: a randomized controlled trial.</a> Top Stroke Rehabil. 19 (3), 193-211 (2012).</li><li>Boyd, L. A., Vidoni, E. D., Wessel, B. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Motor+learning+after+stroke:+is+skill+acquisition+a+prerequisite+for+contralesional+neuroplastic+change?.">Motor learning after stroke: is skill acquisition a prerequisite for contralesional neuroplastic change?.</a> Neuroscience letters. 482 (1), 21-25 (2010).</li><li>Laver, K. E., George, S., Thomas, S., Deutsch, J. E., Crotty, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Virtual+reality+for+stroke+rehabilitation.">Virtual reality for stroke rehabilitation.</a> Cochrane Database Syst Rev. (2), CD008349 (2015).</li><li>Saposnik, G., Levin, M., Outcome Research Canada Working, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Virtual+reality+in+stroke+rehabilitation:+a+meta-analysis+and+implications+for+clinicians.">Virtual reality in stroke rehabilitation: a meta-analysis and implications for clinicians.</a> Stroke. 42 (5), 1380-1386 (2011).</li><li>Lohse, K. R., Hilderman, C. G., Cheung, K. L., Tatla, S., Van der Loos, H. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Virtual+reality+therapy+for+adults+post-stroke:+a+systematic+review+and+meta-analysis+exploring+virtual+environments+and+commercial+games+in+therapy.">Virtual reality therapy for adults post-stroke: a systematic review and meta-analysis exploring virtual environments and commercial games in therapy.</a> PLoS One. 9 (3), e93318 (2014).</li><li>Venugopalan, J., Cheng, C., Stokes, T. H., Wang, M. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> Engineering in Medicine and Biology Society (EMBC), 2013 35th Annual International Conference of the IEEE. , 4625-4628 (2013).</li><li>Sin, H., Lee, G. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Additional+virtual+reality+training+using+Xbox+Kinect+in+stroke+survivors+with+hemiplegia.">Additional virtual reality training using Xbox Kinect in stroke survivors with hemiplegia.</a> Am J Phys Med Rehabil. 92 (10), 871-880 (2013).</li><li>Joo, L. Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+feasibility+study+using+interactive+commercial+off-the-shelf+computer+gaming+in+upper+limb+rehabilitation+in+patients+after+stroke.">A feasibility study using interactive commercial off-the-shelf computer gaming in upper limb rehabilitation in patients after stroke.</a> Journal of rehabilitation medicine. 42 (5), 437-441 (2010).</li><li>Chang, Y. -. J., Chen, S. -. F., Huang, J. -. D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+Kinect-based+system+for+physical+rehabilitation:+A+pilot+study+for+young+adults+with+motor+disabilities.">A Kinect-based system for physical rehabilitation: A pilot study for young adults with motor disabilities.</a> Research in developmental disabilities. 32 (6), 2566-2570 (2011).</li><li>Chen, M. H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+controlled+pilot+trial+of+two+commercial+video+games+for+rehabilitation+of+arm+function+after+stroke.">A controlled pilot trial of two commercial video games for rehabilitation of arm function after stroke.</a> Clin Rehabil. 29 (7), 674-682 (2015).</li><li>Saposnik, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+Virtual+Reality+Exercises+in+STroke+Rehabilitation+(EVREST):+rationale,+design,+and+protocol+of+a+pilot+randomized+clinical+trial+assessing+the+Wii+gaming+system.">Effectiveness of Virtual Reality Exercises in STroke Rehabilitation (EVREST): rationale, design, and protocol of a pilot randomized clinical trial assessing the Wii gaming system.</a> Int J Stroke. 5 (1), 47-51 (2010).</li><li>Saposnik, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effectiveness+of+virtual+reality+using+Wii+gaming+technology+in+stroke+rehabilitation:+a+pilot+randomized+clinical+trial+and+proof+of+principle.">Effectiveness of virtual reality using Wii gaming technology in stroke rehabilitation: a pilot randomized clinical trial and proof of principle.</a> Stroke. 41 (7), 1477-1484 (2010).</li><li>Brunnstrom, S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Motor+testing+procedures+in+hemiplegia:+based+on+sequential+recovery+stages.">Motor testing procedures in hemiplegia: based on sequential recovery stages.</a> Phys Ther Sport. 46 (4), 357-375 (1966).</li><li>Gladstone, D. J., Danells, C. J., Black, S. E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+fugl-meyer+assessment+of+motor+recovery+after+stroke:+a+critical+review+of+its+measurement+properties.">The fugl-meyer assessment of motor recovery after stroke: a critical review of its measurement properties.</a> Neurorehabil Neural Repair. 16 (3), 232-240 (2002).</li><li>Ma, H. -. I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Effects+of+virtual+reality+training+on+functional+reaching+movements+in+people+with+Parkinson's+disease:+a+randomized+controlled+pilot+trial.">Effects of virtual reality training on functional reaching movements in people with Parkinson's disease: a randomized controlled pilot trial.</a> Clinical Rehabilitation. 25 (10), 892-902 (2011).</li><li>Reiterer, V., Sauter, C., Kl&#246;sch, G., Lalouschek, W., Zeitlhofer, J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Actigraphy-a+useful+tool+for+motor+activity+monitoring+in+stroke+patients.">Actigraphy-a useful tool for motor activity monitoring in stroke patients.</a> European neurology. 60 (6), 285-291 (2008).</li><li>Gebruers, N., Vanroy, C., Truijen, S., Engelborghs, S., De Deyn, P. P. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Monitoring+of+physical+activity+after+stroke:+a+systematic+review+of+accelerometry-based+measures.">Monitoring of physical activity after stroke: a systematic review of accelerometry-based measures.</a> Archives of physical medicine and rehabilitation. 91 (2), 288-297 (2010).</li></ol>

All authors declare no conflict of interest.

Patients with stroke usually have disabilities related to motor impairments due to incomplete motor recovery. Such disabilities, lengthy travel time to a clinic, or socioeconomic difficulties can hinder patients&#39; access to adequate rehabilitation therapy. A ubiquitous healthcare (u-Health) program can be a good option for removing those barriers. As a part of such a u-Health program, a mobile game-based VR rehabilitation program was developed for upper limb recovery after ischemic stroke in the present study. Our fin...

Stroke is one of the most common causes of neurological impairment in adults. Recovery from impairment after a stroke is usually incomplete, and approximately 50% of patients are left with disabilities, making them dependent on others1. In particular, upper limb dysfunction makes stroke survivors dependent on others for assistance with activities of daily living (ADL)2. Regaining the lost function in the upper extremities may be more difficult to achieve than returning the normal function of ambulation to the lower extremities. Although bilateral lower extremity movement is indispensable for locomotion, patients can perform ADL with unilateral upper extremity movement. This leads to a learned non-use phenomenon of the affected limb3. This phenomenon is an obstacle to the rehabilitation of the upper extremity in stroke survivors. Therefore, a tremendous amount of research is focused on the upper limb function recovery. Studies have highlighted the importance of extensive practice and repetitive task-specific training4,5,6.
Virtual reality (VR) technology has recently been introduced into the field of rehabilitation7. VR allows users to interact with a simulated environment and receive continuous, immediate feedback related to performance. VR has the potential to apply basic concepts of neurorehabilitation in stroke patients, such as intensive, repetitive, and task-oriented training8. Specifically, non-immersive VR does not require high-level graphics performance or special hardware. Therefore, non-immersive VR is a good candidate for providing a low-cost, ubiquitous, and interesting treatment program. Previous studies used computers, monitors, and special devices, such as consoles, sensor gloves, joy-sticks, and commercial gaming systems for non-immersive VR9. Higher start-up costs and sufficient space were mandatory for using such systems. Recently, low-cost tools, such as commercial gaming devices, have been utilized to develop new rehabilitation systems10,11. However, the consoles with sensors in those devicesare not sufficiently small and lightweight for carrying. Nevertheless, to improve the popularity of non-immersive VR as a post-stroke upper extremity treatment method and to create a ubiquitous rehabilitation environment for stroke survivors, portable and inexpensive tools are needed.
Furthermore, game-based therapy can be a good option for stroke rehabilitation. Many patients complain that conventional occupational therapy (OT) for upper limb function recovery is boring and monotonous12,13. A more interesting and motivating tool for the therapy is, therefore, necessary to promote patients&#39; engagement in rehabilitation training. Many studies that involve the use of commercial games have been conducted14,15,16. However, the games used do not target the desired movement of the upper extremity in patients with stroke, and they lack special consideration for the spasticity that may be present after a stroke.
This paper describes the development of a mobile game-based VR program and its use for patients who have experienced a stroke and suffer from upper limb dysfunction (Figure 1).

<table>
	<tbody>
		<tr>
			<td>Galaxy Note 10.0</td>
			<td>Samsung</td>
			<td>Galaxy Note 10.0</td>
			<td>Tablet PC</td>
		</tr>
		<tr>
			<td>Galaxy S2</td>
			<td>Samsung</td>
			<td>Galaxy S2</td>
			<td>Smartphone</td>
		</tr>
		<tr>
			<td>Bluetooth</td>
			<td>Bluetooth SIG</td>
			<td>Bluetooth</td>
			<td>short-distance wireless connection&#160;</td>
		</tr>
		<tr>
			<td>Java</td>
			<td>Oracle</td>
			<td>Java</td>
			<td>programming language</td>
		</tr>
	</tbody>
</table>

mobile game-based virtual reality program for upper extremity stroke rehabilitation

Stroke rehabilitation requires repetitive, intensive, goal-oriented therapy. Virtual reality (VR) has the potential to satisfy these requirements. Game-based therapy can promote patients&#39; engagement in rehabilitation therapy as a more interesting and a motivating tool. Mobile devices such as smartphones and tablet PCs can provide personalized home-based therapy with interactive communication between patients and clinicians. In this study, a mobile VR upper extremity rehabilitation program using game applications was developed. The findings from the study show that the mobile game-based VR program effectively promotes upper extremity recovery in patients with stroke. In addition, patients completed two weeks of treatment using the program without adverse effects and were generally satisfied with the program. This mobile game-based VR upper extremity rehabilitation program can substitute for some parts of the conventional therapy that are delivered one-on-one by an occupational therapist. This time-efficient, easy to implement, and clinically effective program would be a good candidate tool for tele-rehabilitation for upper extremity recovery in patients with stroke. Patients and therapists can collaborate remotely through these e-health rehabilitation programs while reducing economic and social costs.

A total of 24 patients were enrolled and assigned to either the control or the experimental group (Table 1). A greater improvement in the FMA-UE, B-stage, and manual muscle testing was found after treatment with the mobile game-based VR upper extremity rehabilitation program than with conventional therapy (Figure 3). The effect was maintained until the one-month follow-up. This means MoU-Rehab was not inferior to the conventional therapy that...

Watch this Scientific Journal Video about Mobile Game-based Virtual Reality Program for Upper Extremity Stroke Rehabilitation at JoVE.com

Mobile Game-based Virtual Reality Program for Upper Extremity Stroke Rehabilitation

Here, we present a protocol to develop and apply a mobile game-based virtual reality program for the recovery of upper limb dysfunction in patients with stroke. The present study shows that the mobile program is feasible and effectively promotes upper limb recovery in stroke patients.

Stroke rehabilitation requires repetitive, intensive, goal-oriented therapy. Virtual reality (VR) has the potential to satisfy these requirements. ...

The overall goal of this program is to provide a mobile game-based upper extremity virtual reality program using a combination of two mobile devices, a smartphone and tablet PC, for patients with stroke. This method can help answer key questions in the u-healthcare field regarding home-based telerehabilitation. The main advantage of this technique is that mobile game-based upper extremity virtual reality programs can provide an inexpensive, ubiquitous, motivating, and interesting treatment for stroke patients.The implications of this technique centers toward rehabilitation therapy because a mobile game-based upper extremity program can solve the problems faced by patients who have difficulty traveling to a clinic due to transportation, time, cost, or stroke impairment. Begin by escorting the participant into the therapy room, and have them sit at the desk. Place the tablet PC on the desk, and turn it on.Next, turn on the smartphone, as well as the short-distance wireless connection on the smartphone. Choose the game application on the tablet by touching the screen. Then, put the smartphone in the armband, and attach the armband to the upper arm or forearm of the participant, depending on the desired movement.Choose either the basic or the customized version of the game. Then, according to the participant's ability, select the game speed, time, a number of target movements, and the expected achievement of the game on the touchscreen of the tablet PC on the customized version. Instruct the participant to move their body according to the commands of the game, allowing the maximal range of motion for calibration.Then, have them press the start button to begin. Track the participant's upper extremity movements using the built-in sensors of the smartphone, and transfer information about the movement to the tablet PC through the short-distance wireless connection. Provide visual and auditory feedback for the participant on their movement with the display on the tablet PC.Demonstrate the real achievement of the game as compared with the expected achievement at the end of the game.Finally, observe the participant playing the game. For the Honey Pot Guard game, begin by asking the participant to beat a bear from the honey pot by throwing apples using the movement of the elbow joint. Let the participant throw apples when the flexed elbow is extended.Next, for the Protect the Bunny game, ask the participant to protect the bunny by catching stones with the net using the movement of the shoulder joint. Ensure that the net moves when the adducted shoulder is abducted. Following that, for the Put Out Fire game, ask the participant to put the fire out with the water hose through the window, which is controlled via the motion of the shoulder.Ensure that the water hose moves right and left and up and down corresponding to the motion of the shoulder joint. Lastly, for the Flower Splash game, have the participant use their joint motion to water the moving seed with a watering can and make the flowers blossom. A greater improvement in the Fugl-Meyer Assessment of the upper extremity, Brunnstrom stage, and manual muscle testing was found after treatment with the mobile game-based VR upper extremity rehabilitation program than with conventional therapy.Participants in the experimental group completed the two-week treatment without adverse effects and were generally satisfied based on the provided questionnaire, even though participants had various levels of technology familiarity. While attempting this procedure, it is important to remember to target the desired movement of the upper extremity with special consideration for accompanying problems related to stroke, such as hemiplegic shoulder pain and spasticity. Don't forget that working with this program in a home setting requires monitoring a patient's adherence to the program, and continuous, immediate feedback related to performance should be given to increase interest in motivation in rehabilitation therapy.After its development, this technique paved the way for researchers in the field of rehabilitation by exploring the efficacy and feasibility of a mobile rehabilitation program for the recovery of upper limb function in patients with stroke. After watching this video, you should have a good understanding of how to design and deliver a mobile rehabilitation program. that is, increase the hours of repetitive, goal-oriented therapy without increasing costly therapy time or requiring expensive equipment.

mobile-game-based-virtual-reality-program-for-upper-extremity-stroke

Research

JoVE Journal

Behavior

18.3K visualizações.  Seoul National University College of Medicine, Seoul National University Bundang Hospital. The overall goal of this program is to provide a mobile game-based upper extremity virtual reality program using a combination of two mobile devices, a smartphone and tablet PC, for patients with stroke. This method can help answer key questions in the u-healthcare field regarding home-based telerehabilitation. The main advantage of this technique is that mobile game-based upper extremity virtual reality programs can provide an inexpensive, ubiquitous, motivating, and interesting treatment fo...