Abstract
Background A low-cost virtual reality system that translates movements of the hand, fingers, and thumb into game play was designed to provide a flexible and motivating approach to increasing adherence to home-based rehabilitation.
Objective Effectiveness depends on adherence, so did patients use the intervention to the recommended level? If not, what reasons did they give? The purpose of this study was to investigate these and related questions.
Design A prospective cohort study, plus qualitative analysis of interviews, was conducted.
Methods Seventeen patients recovering from stroke recruited to the intervention arm of a feasibility trial had the equipment left in their homes for 8 weeks and were advised to use it 3 times a day for periods of no more than 20 minutes. Frequency and duration of use were automatically recorded. At the end of the intervention, participants were interviewed to determine barriers to using it in the recommended way.
Results Duration of use and how many days they used the equipment are presented for the 13 participants who successfully started the intervention. These figures were highly variable and could fall far short of our recommendations. There was a weak positive correlation between duration and baseline reported activities of daily living. Participants reported lack of familiarity with technology and competing commitments as barriers to use, although they appreciated the flexibility of the intervention and found it motivating.
Limitations The small sample size limits the conclusions that can be drawn.
Conclusions Level of use is variable and can fall far short of recommendations. Competing commitments were a barrier to use of the equipment, but participants reported that the intervention was flexible and motivating. It will not suit everyone, but some participants recorded high levels of use. Implications for practice are discussed.
After surviving a stroke, many people fail to regain functional use of their impaired upper limb.1 Both meta-analyses and systematic reviews have shown that early intensive,2 task-specific3 practice for a prolonged period of time4 facilitates motor recovery. There are no clear recommendations on how much practice a patient should engage in terms of either duration of rehabilitation or number of repetitions. Most available evidence is on duration.5 A meta-analysis2 concluded that therapy input should be augmented at least 16 hours within the first 6 months after stroke. However, reviewing studies where constraints were applied to the less affected arm, thus forcing patients to use their affected arm, led the authors to suggest a benefit from a high dose over a shorter period of time, specifically 6 hours per day during 2 weeks (ie, augmentation of 60 hours). They also reported that there was no ceiling effect for therapeutic intensity beyond which no further response is observed.
In the United Kingdom, in view of the evidence, the National Clinical Guidelines for Stroke6 recommends that patients are offered initially at least 45 minutes of each appropriate therapy that is required for a minimum of 5 days per week if they have the ability to participate and where functional goals can be achieved. However, the results from a recent national audit suggest that patients are receiving between a quarter and a half of this standard.7 Even when patients do receive rehabilitation, the upper limb receives scant attention, with a recent systematic review reporting the average time spent on upper limb activities during a session as 0.9 to 7.9 minutes.8 On discharge, fewer than half of the patients with a Modified Rankin Scale score of 1 or above are referred for further rehabilitation.
Even if patients are sent home with a home exercise program, adherence to treatment is poor: 50% to 55% of patients with chronic medical conditions fail to adequately adhere to treatment regimens.9 Clay and Hopps10 suggested that one factor that contributes to nonadherence is the perception of treatment regimens as rigid and immutable. Their effectiveness is irrelevant if they exhaust patients' capabilities and motivation. Adherence could be improved if treatments are designed that are amenable or adaptable to more appropriately fit into the lifestyles and limitations of patients and their families.
One route through which adherence may be improved is through the adoption of virtual reality and interactive video gaming, which have emerged as new treatment approaches in stroke rehabilitation.11 Interfacing virtual reality games with robotic arms12 exploits the benefits of these latter systems, which were found in a systematic review13 to have significant improvement in upper limb motor function. However, their cost; location in a laboratory, hospital, or health center; and requirement for specialist technical support limit their availability for most patients. The appearance of commercial gaming consoles such as the Wii (Nintendo, Redmond, Washington) and Kinect (Microsoft Corp, Redmond, Washington) have led to their adoption by therapists in clinical settings.14 These consoles have the advantages of mass acceptability, easily perceived feedback, and—most importantly—affordability for unrestricted home use. However, the games are not specifically designed for therapeutic use, and although some of the games encourage movements of the upper limb, neither the Wii nor the Kinect system captures the movement of the fingers. The more recently appearing Leap Motion (Leap Motion Inc, San Francisco, California) cannot currently capture sufficient information about the position of the fingers to be useful in the rehabilitation of the hand.
We developed a home-based system that uses infrared capture to translate the position of the hand, fingers, and thumb into game play.15 Three games with varying levels of challenge encourage repetitive movements of the hand that underpin activities of daily living (such as reaching, grasping, pointing, moving, and manipulating objects). In line with the Medical Research Council Framework for Complex Interventions,16 a feasibility randomized controlled study was carried out in preparation for an evaluation of the effectiveness of the intervention.
This article examines data collected on the 17 participants who were randomly allocated to receive the intervention to answer the following questions:
How close to the recommended duration were participants using the intervention?
How close to the recommended frequency were participants using the intervention?
What barriers or facilitators did they report to using the intervention at the recommended duration and frequency?
Method
Design
The study used a prospective cohort study plus qualitative analysis of interviews with the intervention group from a 2-group feasibility randomized controlled trial comparing the intervention with usual care.
Participants
For the feasibility study, 29 participants were recruited who were aged 18 years or older, had a confirmed diagnosis of stroke, were no longer receiving any other intensive rehabilitation (intermediate care, early supported discharge), and still had residual upper limb dysfunction. Of the 17 participants who were allocated to the intervention group, 9 were women, and 8 were men. At the point of randomization, the group had a mean age of 59 years (SD=12.03, range=40–82); the median time since stroke onset was 22 weeks (range=6–178). All participants experienced disturbance of fine motor control. Nine participants had right upper limb paresis, and 8 had left upper limb paresis; the affected upper limb was dominant for 13 of the participants.
The Virtual Glove and Games
The intervention was developed based on motor learning theory and aimed to increase the number of repetitions of functional movements while providing games that are challenging, with feedback on performance. Feedback and an element of challenge were included because increasing repetitions alone is not sufficient to drive neuroplasticity,17 with shaping (small steps of increasing difficulty with immediate feedback on performance) also known to improve recovery.18
The Virtual Glove consists of a hand-mounted power unit with 4 infrared light-emitting diodes (LEDs) mounted on the user's fingertips (Fig. 1). The LEDs are tracked using 1 or 2 Nintendo Wii remotes mounted by the personal computer on which the games are displayed to translate the location of the user's hand, fingers, and thumb in three-dimensional space. Games were produced especially for the project with the help of therapists and patients with stroke. In order to play them, users have to perform the movements of reach to grasp, grasp and release, pronation, and supination that are necessary to effect many activities of daily living.
A participant using the Virtual Glove to play Spongeball (described in the text).
Three games were developed in conjunction with users.15 Spacerace required pronation and supination of the hand to guide a spacecraft through obstacles. Spongeball required the user to open his or her fist and extend the fingers in order to release a ball to hit a target. Balloonpop required a balloon to be grasped and popped by moving it to a pin protruding from the floor.
The games were designed to be constantly challenging, with increasing levels of difficulty dependent on ability. This design was to maximize motor learning and to keep the participants motivated to continue to use the system but to ensure that they can achieve some success. Difficulty was increased by greater movement being required to complete a task, an increase in the speed at which events occur and with which responses are required, or an increase in the precision required to complete a task. As the system works on detecting position of the fingers in the glove and not the movement of the wrist, elbow, or shoulder or sitting posture, it was important that a therapist provided initial instruction and subsequent ongoing support, thereby reducing unwanted compensatory movements. Immediate feedback was given by participants' scores being displayed on the screen at the end of a game and a permanent visual display of their progress in terms of scores and levels played. A log of when the system was in use as well as what games were being played and what scores the user obtained was stored on the computer.
Intervention
Participants were randomly allocated to either an intervention group or a control group. Those participants in the intervention group had the Virtual Glove in their homes for a period of 8 weeks and were advised to try to build up to using the system for a maximum of 20 minutes, 3 times a day, for 8 weeks.
Outcome Measures
For the feasibility trial, the outcome measures were: Wolf Motor Function Test,19 Nine-Hole Peg Test,20 Motor Activity Log,21 and Nottingham Extended Activities of Daily Living Scale.22 For the intervention group, the frequency of use of the glove was collected by the software.
Procedure
Ethics approval was obtained from the local NHS Research Ethics Committee before potential participants were recruited from the community stroke teams. Informed consent was obtained and baseline assessments were collected during a home visit before the participant was randomly allocated to the intervention or control group.
For those assigned to the intervention group, 3 procedures were put in place to encourage them to use the equipment at the recommended duration and frequency. First, considerable face-to-face support was provided. The physical therapist or occupational therapist from the research team delivered and set up the equipment. Based on each participant's ability, the therapists drew up a sheet for each individual advising what games to start with and at what level. The glove and games were demonstrated to the participant and his or her caregiver, and they were then trained on how to use the equipment independently. The researchers then arranged to return to repeat this demonstration until they felt that the participant had understood how to use the glove or that there was a caregiver who understood how to use it. The researchers also provided telephone support to check whether the participant had been able to use the equipment and to offer further visits to clarify any outstanding matters if required. After the initial setup and training period, a member of the team visited either weekly or fortnightly, depending on the level of support required, to check progress and retrieve data. Second, the participant was given a telephone number at which a member of the research team could be contacted during working hours if any advice was needed or if the equipment failed. Third, each participant was provided with an instruction manual, which included frequently asked questions and troubleshooting tips.
After 4 weeks, all participants were visited at home for completion of the outcome measures. At the end of the intervention, after the equipment had been collected, participants were invited to take part in a short, semistructured interview to determine their experience of using the glove and barriers to using it in the recommended way and to the recommended levels. Interviews were conducted by a member of the research team with whom the participants were already familiar and audio-recorded. All participants still in the study completed outcome measures at 8 weeks after randomization with a blinded assessor.
Data Analysis
Game data were collated from individual html files into Excel (Microsoft Corp, Redmond, Washington) spreadsheets in order to produce individual participant data on duration of use, number of days on which the glove was used, and number of times the glove was used each day. These data were then transferred to SPSS version 20 (IBM Corp, Armonk, New York) for summarizing. Interviews were transcribed verbatim and anonymized before each one was verified for accuracy by one researcher (K.T.) and analyzed using thematic analysis, a method for identifying and reporting patterns or themes within data.23 All transcripts were read by 2 researchers (C.J.S. and P.J.S.), identifying issues relevant to general rehabilitation and those specific to our intervention before comparing and agreeing on initial codes from the first 5 transcripts and collating codes into potential themes. Remaining transcripts were then coded independently, and the themes jointly identified were reviewed (K.T.) to maximize validity. The full analysis will appear in a subsequent publication. Only those issues that may explain level of use of the intervention are summarized here.
Role of the Funding Source
This research was supported by the National Institute for Health Research through funding to Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Nottinghamshire, Derbyshire, Lincolnshire.
Results
Of the 17 participants who were randomly allocated to the intervention group, 4 did not complete sufficient training to start the intervention. The reasons were: family issues (n=1), intervention “wasn't his thing” (n=1), could not complete training due to arm pain (n=1), and arm pain and severe aphasia (n=1). Midpoint outcome measures were collected at 4 weeks on 12 participants, as 1 participant had already stopped using the glove, having experienced a seizure. Of these 12 participants, 9 completed outcome measures after 8 weeks. The reasons given by those who dropped out were: illness (n=1), ill family member (n=1), and going on extended holiday and so had only a 4-week intervention (n=1). The Table shows the characteristics of the 13 participants (identified as P1, P2, P3, and so on) who successfully started the intervention.
Characteristics of the 13 Participants Who Successfully Started the Interventiona
How Close to the Recommended Duration Were Participants Using the Glove?
In order to answer this question, 2 sets of data were examined: hours of use and days on which the glove was used. For each participant who successfully started the intervention (n=13), the percentage of use of the glove was calculated. As the time the glove was present in participants' homes varied (eg, 1 participant went on holiday after 4 weeks), the hours of use were converted to a percentage of the maximum hours they would have used it if they followed the recommendation of 20 minutes, 3 times a day, while it was in their home. Similarly, number of days on which they used the glove was converted to a percentage of the number of days the glove was in their home (Table, Fig. 2).
Percentage of recommended use expressed in terms of duration and numbers of days for each of the 13 participants.
There was considerable variation both in terms of duration of use and the number of days used. For example, P2 used the glove for only 1.46% of the recommended duration, whereas P9 used it for 70% of the expected duration. Similarly, percentage of days used ranged from 10% to 100%. In an attempt to identify potential predictive factors, use was correlated with age and baseline values of outcome measures, but only the correlation between percentage duration and Nottingham Extended Activities of Daily Living scores (rho=.661, P=.053) approached significance.
If participants were not using the equipment every day, how close to the recommended hour a day were they using it on the days when they did play? Figure 3 shows the median daily duration of use (in minutes) on days when the equipment was in use together with minimum, first quartile, median, third quartile, and maximum durations. Even for the participant with the highest use (P9), the median duration was less than 60 minutes, although the huge variation and maximum value indicate that there were days where use exceeded 90 minutes, and the third quartile indicates that, on approximately a quarter of the days, use exceeded the recommendation.
Median daily duration of use (in minutes) on days when the equipment was in use together with minimum, first quartile, median, third quartile, and maximum durations.
How Close to the Recommended Frequency Were Participants Using the Glove?
We recommended that participants use the glove 3 times a day. When calculating the number of times the glove was used, we defined a time or session as a period of use where onset was more than 20 minutes after the last time the glove was used and where cessation was more than 20 minutes before the next time of use. Figure 4 shows, for each of the 13 participants, the number of days on which they used it 1, 2, 3, or 4 or more times.
Number of days that participants did not use the glove and that they used the glove 1, 2, 3, or 4 or more times a day.
Only 7 participants ever used the glove 3 times a day, but all participants had days where they used it twice. Of note is that for 5 participants, there were days when they used the glove 4 or more times, a frequency that exceeded our recommendation.
What Barriers or Facilitators Did The Participants Report to Using the Glove at the Recommended Duration and Frequency?
After the glove had been collected from participants' homes, 11 participants volunteered to be interviewed. Eight of these participants had completed 8-week outcome measures, and 3 had dropped out before completing the 8-week outcome measures. Thematic analysis of interviews identified several explanations for the low level of use of the glove (barriers) as well as aspects that encouraged them to play (facilitators).
Barriers to Use
Barriers to use included technical issues, dependence, health problems, competing commitments, and return to prestroke life.
Technical issues.
Technical issues that arose due to the glove being a prototype could restrict use. For example, use of the glove could be disrupted by bright sunlight or excessive infrared emission from other equipment in the participant's home. P4 reported on a few occasions that these made her want to throw the computer out of the window. Although participants had our telephone number, they did not always contact us for assistance when experiencing technical issues. For instance, P13 reported that when she could not get the glove to successfully work, she would sit in front of the computer and simulate the hand movements that she would make when actually playing the games, as she did not want to miss a session.
Technical confidence and experience.
Technical confidence and experience, if low, limited use of the equipment. P4 reported that sometimes she spent more time setting up than playing. That led her to prefer just one session a day: “Yes, I got into it quickly towards the end, but at the beginning it seemed to take ages to get organized.” However, if the participant's previous use of computers had involved frequent game playing, the games were likely to become boring: “I started to sort of lose interest a little bit, I think. But I think that was more to do with I'm used to playing on computers, and I found that the games were a bit repetitive for me.” (P8)
Dependence on someone to help with equipment.
Dependence on someone to help with equipment could be a barrier to use. For example, P4 could not change the batteries in the Wii remote on her own, which meant that she had to call the research team to change them for her unless her son was visiting. For P24: “If she (my daughter) wasn't here, if she was at work, I'd used it later in the day when she came home.”
Health problems.
Several participants experienced episodes of ill health such as flu that prevented them from using the glove. A subtheme within this barrier was fatigue, as many people recovering from stroke experience periods of disabling fatigue that require periods of rest throughout the day: “In my first 4 months, I was really a bit tired every day…. I don't think I'd have had the chance to do that (use the glove).” (P9) A second subtheme was mood: one participant mentioned the barrier of periods of depression that can occur during recovery from stroke: “Because you do get the mood swings with strokes. You might get them on a down day and then just think, ‘oh, what the hell.’” (P3)
Competing commitments.
Competing commitments such as looking after grandchildren could prevent participants using the glove: “And what time the family came, if the family came just when I had started it, I had to then leave it.” (P4) Some participants had arranged private therapy sessions: “Yeah, well, because there's so much more—you know, you've got your physio [physical therapist] to fit in” (P3), and there were less demanding activities: “I admit it depended what was on the telly.” (P4)
Return to prestroke life.
Inevitably, as participants recovered, they wanted to return to their prestroke life, especially if they were mobile. This barrier to use included returning to work, going on holiday, driving, or hobbies: “I've got my allotments to do; there's obviously going out shopping and…trying to fit round the rest of your day.” (P3)
Facilitators of Use
Facilitators of use included the flexibility of the intervention, its motivating qualities, alleviation of boredom, belief in its therapeutic nature, and family support.
Flexibility of the intervention.
The flexibility of the intervention was appreciated by the participants. One participant said, “Whereas with a computer you could [use the glove at], say, 4 o'clock/5 o'clock, if you felt all right, you could do it sort of any time you wanted to. You're not set to a time all the time, which was quite good.” (P8) Another said, “I'll put the kettle on. While I'm waiting for the kettle to boil, I can have a play with it, or, you know, when I'm doing dinner, while the dinner's cooking, I'll have a play with the computer.” (P3)
Finding games motivating.
The immersive nature of computer games has been long recognized as an explanation of why some young people play them for long periods, and our games shared that characteristic for some participants: “You don't always know how much you're on there for. It's quite addictive in some ways.” (P23) One reason for this motivation was the competitive nature of the games: “Yeah, well, I was trying to do that, beat the score from previous.” (P24)
Alleviation of boredom.
Alleviation of boredom could facilitate use: “When I got bored, I just used it.” (P24)
Belief in its therapeutic nature.
One participant responded, “Because it helps—well, it helps you a lot in your movement. First and foremost, with the position, you know, then you enjoy the games.” (P9)
Family support.
Family support was crucial: “My granddaughter used to play the Balloonpop and encouraged me. I mean, obviously she got fantastic scores that I wouldn't be able to achieve, but I was so there, wanting to get as much as I could…. It's good to have other people to play with you because you said, you know, that we could set her up, and we did.” (P23)
Discussion
Performance data collected by the software showed that for those who did use the intervention, the duration of use and on how many days they used the glove were highly variable and could fall far short of our recommendations. The recorded figures are an underestimate, as they do not take account of the period in which participants were following our advice to build up to the recommended level of use. However, our recommendations were not based on hard evidence and were a compromise between results from systematic reviews on duration, rather than frequency of making a particular movement, and what pilot work indicated would be practical for participants to achieve and not too demotivating. We also wanted to discourage participants from prolonged use to avoid fatigue or the development of side effects24 before we could visit to check on whether they were continuing to use the glove without causing fatigue or shoulder pain. As a dose-response relationship has been shown for practice and recovery,2 any increase in activity is beneficial.
Factors that might be associated with variation in use can be suggested from an examination of both the participant characteristics and the themes emerging from the interview analysis. Although not a direct measure of upper limb ability, the weak relationship with reported activities of daily living suggests that higher levels of ability to care for oneself are associated with more use of the glove and games. This increased use may be because higher levels of activities of daily living are a proxy for either the ability to set up the equipment or for having more time for the intervention due to activities of daily living being more quickly completed. There was no correlation with age: 2 of those participants who used it the most were women over 70 years of age, suggesting that age is not necessarily a barrier.
Of the explanations that emerged from the interviews, some (eg, illness, other commitments, getting back to prestroke life) would apply to any home-based, self-managed therapy. Others were specific to this particular intervention, such as being dependent on someone to help with equipment setup and computer literacy. If someone has had little experience with computers before having a stroke, this skill may be more vulnerable to disruption through the stroke or lack of use. However, more and more people now use computers and smartphones, and those now at retiring age, unlike their predecessors, are more likely to have used computers in the workplace. Thus, as the population becomes more computer literate, this is less likely to be a barrier.
The rationale for developing the intervention had been to provide a flexible10 and motivating way of exercising the upper limb, and analysis of interviews indicated that participants appreciated the flexibility of the intervention and its ability to motivate them to use it more. Some participants with less impairment were already trying to get back to work or other activities they had pursued before their stroke, thus limiting the time they had for the intervention. Jones et al stated that self-management programs need to reflect the diversity of individual responses and needs but also that “some individuals may not have the capacity to take on responsibility for their own health at a time when they may be still learning to adjust to losses and challenges.”25(p260) Our intervention was introduced at a time when we hoped that participants had managed some of these adjustments. However, the diversity that Jones et al mention must also take account of the different rate at which people recover poststroke and start to engage in competing activities. Interestingly, none of the 13 participants mentioned physical issues as a barrier.
Unlike other unsupervised home-based self-managed therapies, this study was able to collect an accurate record of when participants did their therapy. If they had used their unaffected hand or let someone else play without entering the “guest” user code, their record of play would have looked very different, so we were able to check for the presence of abnormal patterns of use. What we do not know is how much use these participants would have made of an alternative, nontechnological method of unsupervised rehabilitation. Self-report9 indicates that it would be low. The glove was left with participants for up to 8 weeks, which is a longer exposure than many upper limb interventions1,26 but is a long time to ask people to adhere to use, especially if they are trying to return to their prestroke life.
This intervention shows promise in being the flexible and motivating approach required to provide the opportunities for rehabilitation needed to regain optimal functioning of the upper limb poststroke. However, it would be regrettable if this type of approach were seen as an alternative to the hands-on involvement of a therapist rather than supplementing the limited amount of time therapists have available for each patient. As this was a research study, participants received a considerable amount of support from the research team, which suggests that as a therapeutic intervention, this therapy would still need input from a therapist to be successful. Future research is needed to identify what factors make it more likely patients will use an unsupervised, technical, home-based therapy and to explore how to increase use in those who are less likely to use it.
In conclusion, performance data collected by the software from 13 participants allocated to the intervention group in a feasibility randomized controlled study indicate just how variable was the use of our home-based intervention for rehabilitation of the upper limb and how far short of the recommendations use was. Interviews with participants at the end of the intervention indicated that barriers to recommended use could be specific to the technology but also could apply to other unsupervised home-based therapy. However, participants found this intervention flexible and motivating, indicating its potential for improving the opportunity for rehabilitation of the upper limb following stroke.
Footnotes
Ms Standen, Ms Threapleton, Ms Connell, Mr Brown, Mr Battersby, and Ms Platts provided concept/idea/research design. Ms Standen, Ms Threapleton, Ms Connell, Mr Richardson, and Mr Brown provided writing. Ms Threapleton and Mr Richardson provided data collection. Ms Standen, Ms Threapleton, Ms Connell, and Ms Sutton provided data analysis. Ms Standen, Ms Threapleton, and Mr Brown provided project management. Ms Standen and Mr Brown provided fund procurement. Mr Brown and Ms Platts provided facilities/equipment. Mr Brown provided institutional liaisons. Ms Connell, Mr Richardson, Mr Brown, and Mr Battersby provided consultation (including review of the manuscript before submission).
This research was presented at the UK Stroke Forum Conference; December 3–5, 2013; North Yorkshire, United Kingdom.
This research was supported by the National Institute for Health Research through funding to Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Nottinghamshire, Derbyshire, Lincolnshire.
- Received November 25, 2013.
- Accepted August 28, 2014.
- © 2015 American Physical Therapy Association
References
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