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      Competitive and cooperative arm rehabilitation games played by a patient and unimpaired person: effects on motivation and exercise intensity

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          Abstract

          Background

          People with chronic arm impairment should exercise intensely to regain their abilities, but frequently lack motivation, leading to poor rehabilitation outcome. One promising way to increase motivation is through interpersonal rehabilitation games, which allow patients to compete or cooperate together with other people. However, such games have mainly been evaluated with unimpaired subjects, and little is known about how they affect motivation and exercise intensity in people with chronic arm impairment.

          Methods

          We designed four different arm rehabilitation games that are played by a person with arm impairment and their unimpaired friend, relative or occupational therapist. One is a competitive game (both people compete against each other), two are cooperative games (both people work together against the computer) and one is a single-player game (played only by the impaired person against the computer). The games were played by 29 participants with chronic arm impairment, of which 19 were accompanied by their friend or relative and 10 were accompanied by their occupational therapist. Each participant played all four games within a single session. Participants’ subjective experience was quantified using the Intrinsic Motivation Inventory questionnaire after each game, as well as a final questionnaire about game preferences. Their exercise intensity was quantified using wearable inertial sensors that measured hand velocity in each game.

          Results

          Of the 29 impaired participants, 12 chose the competitive game as their favorite, 12 chose a cooperative game, and 5 preferred to exercise alone. Participants who chose the competitive game as their favorite showed increased motivation and exercise intensity in that game compared to other games. Participants who chose a cooperative game as their favorite also showed increased motivation in cooperative games, but not increased exercise intensity.

          Conclusions

          Since both motivation and intensity are positively correlated with rehabilitation outcome, competitive games have high potential to lead to functional improvement and increased quality of life for patients compared to conventional rehabilitation exercises. Cooperative games do not increase exercise intensity, but could still increase motivation of patients who do not enjoy competition. However, such games need to be tested in longer, multisession studies to determine whether the observed increases in motivation and exercise intensity persist over a longer period of time and whether they positively affect rehabilitation outcome.

          Trial registration

          The study is not a clinical trial. While human subjects are involved, they participate in a single-session evaluation of a rehabilitation game rather than a full rehabilitation intervention, and no health outcomes are examined.

          Electronic supplementary material

          The online version of this article (doi:10.1186/s12984-017-0231-4) contains supplementary material, which is available to authorized users.

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          Most cited references36

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          Recovery of motor function after stroke.

          The natural history of recovery of motor function after stroke is described using data from a 1-year community-based study in Auckland, New Zealand. Of 680 patients, 88% presented with a hemiparesis; the proportion of survivors with a persisting deficit declined to 71% at 1 month and 62% at 6 months after the onset of the stroke. At onset, there were equal proportions of people with mild, moderate, and severe motor deficits, but the majority (76%) of those who survived 6 months had either no or only a mild deficit. Recovery of motor function was associated with the stroke severity but not with age or sex; patients with a mild motor deficit at onset were 10 times more likely to recover their motor function than those with a severe stroke. Our results confirm the reasonably optimistic outcome for survivors of stroke and further suggest that recovery of motor function is confined to patients whose motor deficit at onset is either mild or moderate.
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            Impact of intensity of practice after stroke: issues for consideration.

            The present debate paper addresses four relevant issues related to the impact of intensity of practice after stroke. First, the best way to define intensity of practice is discussed. Second, the paper describes the evidence that exists for a dose-response relationship in stroke rehabilitation. Third, the relevance of an appropriate patient selection for a meaningful intensive practice is explored. Finally, the paper raises the question of what it is that patients actually learn when they improve their functional skills. Search strategy. For this purpose articles from MEDLINE, CINAHL, Cochrane Central Register of Controlled Trials, PEDro, DARE and PiCarta and references presented in relevant publications were examined. Although, there is strong evidence that early augmented exercise therapy time (expressed as time dedicated to practice) may enhance functional recovery, there is a discrepancy between the evidence for the benefits of intensive practice, on the one hand, and, the implementation of intensive rehabilitation treatment programmes in the current healthcare system on the other. Further emphasis should be given on a better understanding of the time-dependency of prognostic factors that determine the effectiveness of intensive practice in patients with stroke. In addition, a better understanding is needed of the neurophysiological and biomechanical mechanisms that underlie compensation-related learning of functional tasks after stroke.
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              Qualitative analysis of stroke patients' motivation for rehabilitation.

              To explore the attitudes and beliefs of stroke patients identified by professionals as having either "high" or "low" motivation for rehabilitation. Qualitative study with semistructured interviews. The stroke unit of an inner city teaching hospital. 22 patients with stroke who were undergoing rehabilitation; 14 with high motivation for rehabilitation and eight with low motivation. All patients thought rehabilitation was important for recovery. High motivation patients were more likely to view rehabilitation as the most important means of recovery and to accord themselves an active role in rehabilitation. These patients were also more likely to understand rehabilitation and in particular to understand the specialist role of the nursing staff. Many patients reported independence at home as a personal goal, though few low motivation patients related this goal to success in rehabilitation. Information from professionals about rehabilitation, favourable comparisons with other stroke patients, and the desire to leave hospital had a positive effect on motivation. Conversely, overprotection from family members and professionals, lack of information or the receipt of "mixed messages" from professionals, and unfavourable comparisons with other patients had a negative effect. There are some differences in beliefs between stroke patients identified as having low or high motivation for rehabilitation. These beliefs seem to be influenced by the environment in which the patient is rehabilitated. Professionals and carers should be made aware of the ways in which their behaviour can positively and negatively affect motivation.
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                Author and article information

                Contributors
                mgorsic@uwyo.edu
                imre.cikajlo@ir-rs.si
                dnovak1@uwyo.edu
                Journal
                J Neuroeng Rehabil
                J Neuroeng Rehabil
                Journal of NeuroEngineering and Rehabilitation
                BioMed Central (London )
                1743-0003
                23 March 2017
                23 March 2017
                2017
                : 14
                : 23
                Affiliations
                [1 ]ISNI 0000 0001 2109 0381, GRID grid.135963.b, Department of Electrical and Computer Engineering, , University of Wyoming, ; 1000 E University Avenue, Laramie, WY 82071 USA
                [2 ]ISNI 0000 0000 9418 2466, GRID grid.418736.f, , University Rehabilitation Institute, Republic of Slovenia, ; Linhartova 51, SI 1000 Ljubljana, Slovenia
                Author information
                http://orcid.org/0000-0001-9143-2682
                Article
                231
                10.1186/s12984-017-0231-4
                5363008
                28057016
                75a1ae67-8d36-485e-a699-3264ba8e08f6
                © The Author(s). 2017

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                History
                : 2 July 2016
                : 10 March 2017
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/100000057, National Institute of General Medical Sciences;
                Award ID: P20GM103432
                Award ID: 5U54GM104944
                Award Recipient :
                Categories
                Research
                Custom metadata
                © The Author(s) 2017

                Neurosciences
                rehabilitation,virtual reality,multiplayer games,interpersonal rehabilitation games,social interaction,motivation,exercise intensity

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