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In this paper, we propose a game adaptation technique that seeks to improve the training outcomes of stroke patients during a therapeutic session. This technique involves the generation of customized game levels, which difficulty is dynamically adjusted to the patients’ abilities and performance. Our goal was to evaluate the effect of this adaptati...
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Context 1
... he reported playing only 8 to 10 min instead of the actual 30 minutes played. The game was adapted to the patient, i.e., not very easy (2) and not very difficult (3). Table 1 Subjects Patient 1 2 3 4 5 6 7 Age 52 67 71 58 72 38 73 Gender W The tasks were easy to understand (2) and the game's objective was clear to him (3). Finally, the therapists reported that the game was interesting, and appeared well-adapted to stroke patients. ...
Similar publications
Background
Serious games have been used as supportive therapy for traditional rehabilitation. However, most are designed without a systematic process to guide their development from the phases of requirement identification, planning, design, construction, and evaluation, which reflect the lack of adaptation of rehabilitation requirements and thus t...
Citations
... Gloreha Aria (R-Lead) can provide patients with clear and meaningful feedback coupled with specific goals for occupational therapy sessions. The system's ability to dynamically adjust the level of difficulty of the exergames based on each patient's abilities is critical to ensuring that the game remains engaging and conducive to meaningful progress, particularly for patients recovering from stroke who may face numerous challenges and frustrations due to motor impairments [44,45]. ...
... From an organisational point of view, even more than one unit of such VR devices can be placed in a gym room and managed by one therapist to maximise efficiency and limit the cost of treatments. From a clinical perspective, gamification can increase the effectiveness of the session by stimulating neuroplasticity and promoting patient engagement and motivation, which cannot be taken for granted given the typically long recovery period after stroke [43][44][45]. ...
In post-stroke patients, the disabling motor deficit mainly affects the upper limb. The focus of rehabilitation is improving upper limb function and reducing long-term disability. This study aims to evaluate the feasibility of using the Gloreha Aria (R-Lead), a sensor-based upper limb in-hospital rehabilitation, compared with conventional physiotherapist-led training in subacute hemiplegic patients. Twenty-one patients were recruited and randomised 1:1 to a sensor-based group (treatment group TG) or a conventional group (control group, CG). All patients performed 30 sessions of 30 min each of dedicated upper limb rehabilitation. The Fugl–Meyer Assessment for Upper Extremity (FMA-UE) was the primary evaluation., both as a motor score and as individual items. Secondary evaluations were Functional Independence Measure; global disability assessed with the Modified Barthel Index; Motor Evaluation Scale for UE in stroke; power grip; and arm, shoulder, and hand disability. All the enrolled patients, 10 in the TG and 11 in the CG, completed all hand rehabilitation sessions during their hospital stay without experiencing any adverse events. FMA-UE scores in upper limb motor function improved in both groups [delta change CG (11.8 ± 9.2) vs. TG (12.7 ± 8.6)]. The score at T1 for FMA joint pain (21.8 vs. 24 best score) suggests the use of the Gloreha Aria (R-Lead) as feasible in improving arm function abilities in post-stroke patients.
... Dynamic adaptability in difficulty was incorporated into the training regimen to enhance patient motivation and promote better recovery, as supported by promising findings in the literature [50][51][52]. This adaptive approach aimed to cater to the evolving skill levels and progress of individual participants. ...
Background
Effective stroke rehabilitation requires high-dose, repetitive-task training, especially during the early recovery phase. However, the usability of upper-limb rehabilitation technology in acute and subacute stroke survivors remains relatively unexplored. In this study, we introduce subacute stroke survivors to MyoGuide, a mobile training platform that employs surface electromyography (sEMG)-guided neurofeedback training that specifically targets wrist extension. Notably, the study emphasizes evaluating the platform’s usability within clinical contexts.
Methods
Seven subacute post-stroke patients (1 female, mean age 53.7 years, mean time post-stroke 58.9 days, mean duration per training session 48.9 min) and three therapists (one for eligibility screening, two for conducting training) participated in the study. Participants underwent ten days of supervised one-on-one wrist extension training with MyoGuide, which encompassed calibration, stability assessment, and dynamic tasks. All training records including the Level of Difficulty (LoD) and Stability Assessment Scores were recorded within the application. Usability was assessed through the System Usability Scale (SUS) and participants’ willingness to continue home-based training was gauged through a self-developed survey post-training. Therapists also documented the daily performance of participants and the extent of support required.
Results
The usability analysis yielded positive results, with a median SUS score of 82.5. Compared to the first session, participants significantly improved their performance at the final session as indicated by both the Stability Assessment Scores (p = 0.010, mean = 229.43, CI = [25.74–433.11]) and the LoD (p < 0.001; mean: 45.43, CI: [25.56–65.29]). The rate of progression differed based on the initial impairment levels of the patient. After training, participants expressed a keen interest in continuing home-based training. However, they also acknowledged challenges related to independently using the Myo armband and software.
Conclusions
This study introduces the MyoGuide training platform and demonstrates its usability in a clinical setting for stroke rehabilitation, with the assistance of a therapist. The findings support the potential of MyoGuide for wrist extension training in patients across a wide range of impairment levels. However, certain usability challenges, such as donning/doffing the armband and navigating the application, need to be addressed to enable independent MyoGuide training requiring only minimal supervision by a therapist.
... Furthermore, apps can often make playful interventions in the form of serious games. Serious games have rehabilitation as their primary goal while combining entertainment, attentional engagement, and problem-solving abilities (17). In addition, they conform to the multimotor relearning principles that form the basis of effective neurorehabilitation interventions (18). ...
Introduction
Exercise rehabilitation is crucial for neurological recovery in hemiplegia-induced upper limb dysfunction. Technology-assisted cortical activation in sensorimotor areas has shown potential for restoring motor function. This study assessed the feasibility of mobile serious games for stroke patients' motor rehabilitation.
Methods
A dedicated mobile application targeted shoulder, elbow, and wrist training. Twelve stroke survivors attempted a motor task under two conditions: serious mobile game-assisted and conventional rehabilitation. Electroencephalography and electromyography measured the therapy effects.
Results
Patients undergoing game-assisted rehabilitation showed stronger event-related desynchronization (ERD) in the contralateral hemisphere's motor perception areas compared to conventional rehabilitation (p < 0.05). RMS was notably higher in game-assisted rehabilitation, particularly in shoulder training (p < 0.05).
Discussion
Serious mobile game rehabilitation activated the motor cortex without directly improving muscle activity. This suggests its potential in neurological recovery for stroke patients.
... In 2009, Burke et al. determined the principles of game design suitable for upper limb stroke rehabilitation, and several games were developed and showcased based on these principles [5]. Based on this premise, the challenge of customizing games for rehabilitation purposes, as stated in [7], lies in rehabilitation complexity, as it often demands human involvement. For instance, research on game usability has been conducted where assessment involved interviewing both rehabilitators and their patients [4]. ...
... The primary issue with this approach is the adjustment of game parameters. Hocine et al. [7] detailed a universal technique for adjusting the difficulty of games intended for upper-limb rehabilitation, focusing on modifying pointing tasks and creating game levels. González-González et al. [9] proposed a recommender system which is able to provide the user with personalized games according to their history and skills. ...
... Indeed, one of the main characteristics of a successful game is its ability to provide the player with an appropriate level of difficulty. In the context of physical rehabilitation, the difficulty of the game is a key factor in training, as it can influence the patient's performance [25]. In serious games, the goal of adaptation is to facilitate a game that optimally assists users in their training efforts, learning, etc. ...
... The data analysis module visualizes movement trajectories and joint angles to monitor patient progress. Hocine et al. [25] proposed a game adaptation technique, which is based on the adaptation of scoring tasks and the generation of personalized game levels. The difficulty is dynamically adjusted to patient's abilities and performance. ...
... Because in upper limb motor rehabilitation, patient fatigue must be prevented [25], and in order to maintain the patient's motivation and engagement, we decided to analyze their previous performances and assign them a game difficulty level adapted to their current level, so as to make the game neither very easy nor very difficult for them, and to promote intensity, which is one of the crucial criteria in the motor rehabilitation process. ...
The aim of this work is to present an adaptive serious game based on virtual reality (VR) for functional rehabilitation of the hand after stroke. The game focuses on simulating the palmar grasping exercise commonly used in clinical settings. The system’s design follows a user-centered approach, involving close collaboration with functional rehabilitation specialists and stroke patients. It uses the Leap motion controller to enable patient interaction in the virtual environment, which was created using the Unity 3D game engine. The system relies on hand gestures involving opening and closing movements to interact with virtual objects. It incorporates parameters to objectively measure participants’ performance throughout the game session. These metrics are used to personalize the game’s difficulty to each patient’s motor skills. To do this, we implemented an approach that dynamically adjusts the difficulty of the exergame according to the patient’s performance during the game session. To achieve this, we used an unsupervised machine learning technique known as clustering, in particular using the K-means algorithm. By applying this technique, we were able to classify patients’ performance into distinct groups, enabling us to assess their skill level and adapt the difficulty of the game accordingly. To evaluate the system’s effectiveness and reliability, we conducted a subjective evaluation involving 11 stroke patients. The standardized System Usability Scale (SUS) questionnaire was used to assess the system’s ease of use, while the Intrinsic Motivation Inventory (IMI) was used to evaluate the participants’ subjective experience with the system. Evaluations showed that our proposed system is usable and acceptable on a C-level scale, with a good adjective score, and the patients perceived a high intrinsic motivation.
... Research efforts were put in the last decade on developing personalized interventions, inclusive education strategies, and personalized learning systems. In fact, advances in educational technologies have created many opportunities to aid instructors in personalized learning, including educational and training robots (Lee, Kwon, Kim, & Shin, 2015), adaptive learning and training tools (Popov & Ivanova, 2020) (Hocine et al., 2015) as well as mobile learning systems (Zare, 2011) (Buzzi, Buzzi, Perrone, & Senette, 2019). The personalization of learning consists generally in tailoring instruction, assignments, and assessments by taking into account learners' capabilities and learning needs (Patrick, Kennedy, & Powell, 2013) (Basham, Hall, Carter, & Stahl, 2016). ...
A lack of access to learning opportunities is among the main reasons for social exclusion of people with cognitive disabilities in the professional field. It has been accentuated in the last few years by the rapid development of online learning strategies that limit the physical presence of students and instructors. Personalized systems can help overcome access barriers in learning for people with disabilities by helping them learn autonomously without the direct intervention of tutors. However, despite the wide range of research initiatives in this area to deal with individual differences, learners with cognitive disabilities still suffer from a lack of consideration of their conditions. Indeed, most e-learning platforms have been designed without taking into account users with multiple profiles and impairments. This paper systematically reviewed papers to provide insights about personalization within e-learning systems. We highlight personalization goals and approaches and review whether they improve learning accessibility and outcomes. The objective is to discuss the strengths and weaknesses of current research and suggest some opportunities to improve research in personalized e-learning systems for people with cognitive disabilities.
... Serious games can be understood as games primarily used for educational, rehabilitative or therapeutic purposes. 90 A high level of acceptance and satisfaction was reported on the use of a gesture-based serious game for motor rehabilitation managed through a web platform. 43 A Virtual, augmented, or mixed reality VR can be described as a type of graphical user interface that displays a computer-generated immersive, three-dimensional, interactive environment that can be accessed and manipulated using, for example, stereo headphones, head-mounted stereo television goggles, and data-gloves. ...
Objective:
To identify, map and synthesize the extent and nature of existing studies on the use of home-based digital technology to support post-stroke upper limb rehabilitation.
Data sources:
A comprehensive literature search was completed between 30 May 2022 and 05 April 2023, from seven online databases (CINAHL, Cochrane Library, PubMed, ScienceDirect, IEEExplore, Web of Science and PEDro), Google Scholar and the reference lists of already identified articles.
Methods:
A scoping review was conducted according to Arksey and O'Malley (2005), and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews. All English-language studies reporting on the use of home-based digital technology to support upper limb post-stroke rehabilitation were eligible for inclusion.
Results:
The search generated a total of 1895 records, of which 76 articles met the inclusion criteria. Of these, 52 were experimental studies and the rest, qualitative, case series and case studies. Of the overall 2149 participants, 2028 were stroke survivors with upper limb impairment. The majority of studies were aimed at developing, designing and/or assessing the feasibility, acceptability and efficacy of a digital system for poststroke upper limb rehabilitation in home settings. The thematic analysis found six major categories: Tele-rehabilitation (n = 29), games (n = 45), virtual reality (n = 26), sensor (n = 22), mobile technology (n = 22), and robotics (n = 8).
Conclusion:
The digital technologies used in post-stroke upper limb rehabilitation were multimodal, and system-based comprising telerehabilitation, gamification, virtual reality, mobile technology, sensors and robotics. Furthermore, future research should focus to determine the effectiveness of these modalities.
... Including failures and successes in the game can create a sense of accomplishment and motivation for the players to keep playing and improving their skills. 53 Previous studies [54][55][56] Likewise, the aims of the game are also an essential parameter. ...
Background and Aims
Upper limb disabilities are one of the most common disabilities among different groups of people who always need rehabilitation. One of the important methods in helping to carry out efficient rehabilitation processes and exercises is the use of games. The aim of this study is to identify the parameters necessary to design a successful rehabilitation game and the outcomes of using these games in upper limb disabilities rehabilitation.
Methods
This scoping review was conducted by searching the Web of Science, PubMed, and Scopus. The eligibility criteria were: any form of game‐based upper limb rehabilitation, published in a peer‐reviewed journal, published in English, and not include articles that did not focus upper limb disabilities rehabilitation games, review, meta‐analysis, or conference papers. Analysis of collected data was done using descriptive statistics (frequency and percentage).
Results
The search strategy retrieved 537 relevant articles. Finally, after removing irrelevant and repetitive articles, 21 articles were included in this study. Among the six categories of diseases or complications of upper limb disabilities, games were mostly designed for stroke patients. Smart wearables, robots and telerehabilitation were three technologies that were used for rehabilitation along with games. Sports and shooters were the most used games for upper limb disability rehabilitation. Among 99 necessary parameters for designing and implementing a successful rehabilitation game in ten categories. “Increasing the patient's motivation to perform rehabilitation exercises”, “Game difficulty levels”, “Enjoying and the attractiveness of the game for patients”, and “Providing positive or negative audiovisual feedback” were the most important parameters. “Improvement in musculoskeletal performance” and “Increasing users' enjoyment/joy of therapeutic exercises and their motivation to perform these exercises” were the most important positive outcomes, and “Mild discomfort such as nausea and dizziness when using games” was the only negative outcome.
Conclusions
The successful design of a game according to the parameters identified in the present study can lead to an increase in the positive outcomes of using games in the rehabilitation of disabilities. The study results indicate that upper limb therapeutic exercise augmented with virtual reality games may be highly effective in enhancing motor rehabilitation outcomes.
... VR/AR provides a means to guide and correct patients' motor behavior, enhancing their learning and motivation during rehabilitation [70][71][72][73]. VR/AR systems have been shown to yield better results when used as an adjunct to conventional rehabilitation [74][75][76][77][78]. For instance, the NeuroR system, based on mirror therapy, shows the user's image mirrored in a virtual environment, with a virtual arm replacing the affected arm [18,73,74]. ...
... VR/AR systems have been shown to yield better results when used as an adjunct to conventional rehabilitation [74][75][76][77][78]. For instance, the NeuroR system, based on mirror therapy, shows the user's image mirrored in a virtual environment, with a virtual arm replacing the affected arm [18,73,74]. The user attempts to physically perform arm movements using the impaired arm, and the electromyography (EMG)based human-computer interface triggers the movement of the virtual arm. ...
Virtual reality (VR) and augmented reality (AR) are noble adjunctive technologies currently being studied for the neuro-rehabilitation of post-stroke patients, potentially enhancing conventional therapy. We explored the literature to find if VR/AR improves neuroplasticity in stroke rehabilitation for a better quality of life. This modality can lay the foundation for telerehabilitation services in remote areas. We analyzed four databases, namely Cochrane Library, PubMed, Google Scholar, and Science Direct, by searching the following keywords: ("Stroke Rehabilitation" [Majr]) AND ("Augmented Reality" [Majr]), Virtual Augmented Reality in Stroke Rehabilitation. All the available open articles were reviewed and outlined. The studies conclude that VR/AR can help in early rehabilitation and yield better results in post-stroke patients in adjunct to conventional therapy. However, due to the limited research on this subject, we cannot conclude that this information is absolute. Moreover, VR/AR was seldom customized according to the needs of stroke survivors, which would have given us the full extent of its application. Around the world, stroke survivors are being studied to verify the accessibility and practicality of these innovative technologies. Observations conclude that further exploration of the extent of the implementations and efficacy of VR and AR, combined with conventional rehabilitation, is fundamental.
... As a result, the player can feel bored, frustrated or disappointed and stop playing the game failing to complete the educational purpose of the game. Consequently, the adaptation of a game to its application context may play a crucial role in ensuring the game's acceptability [13]. ...
... In educational games, the adaptation has to be realized in two dimensions: (i) the game's educational content, and (ii) the game's missions and elements. In literature review there are many researchers that have deal with the adaptation of the educational content of an educational game to the abilities of players [2,11,13,18,19,23,25,30,31]. However, it does not occur the same for the adaptation of game's missions and elements of the educational game to the playing skills of the users. ...
An educational game aims to employ the pleasant and fascinating environment of a game for educational purpose. However, when the game’s educational content or playing environment does not match with the player’s learning needs or game-playing skills, the player can find the game either too easy or too difficult and decide to drop it. Therefore, a successful educational game has to offer Dynamic Difficulty Adjustment (DDA) of both the game’s educational content and the game’s playing environment. Considering the above, in this paper a fuzzy-based DDA mechanism of a 3D-game, that teaches the programming language ‘HTML’, is presented. The game adapts dynamically the difficulty of battles and mazes navigation to each individual player’s skills. The novelty of the presented game lies on the application of DDA in the two dimensions (educational content and playing environment) of an educational game and on the use of fuzzy logic for succeeding balance between the game’s difficulty and the user’s playing skills. The adaptation is realized in real-time, during the playing and not each time the player changes game level/track. Furthermore, fuzzy logic allows to apply DDA without the need of many learning data, like other Artificial Intelligence techniques for DDA (i.e. machine learning techniques). The presented game was evaluated through a comparative evaluation, which included questionnaires, an experiment in real conditions and t-test statistical analysis method. The evaluation results showed that the incorporated adaptation mechanism increases the user’s motivation and succeeds to keep players’ interest for the game undiminished.
