Background

1. Can a home based virtual reality system improve the opportunity for rehabilitation of the upper limb following stroke? PJ Standen1, K Threapleton1 , L Connell2 , A Richardson3, DJ Brown4 , S Battersby4 and F Platts5 ¹Division of Rehabilitation and Ageing, University of Nottingham  ² School of Health, University of Central Lancashire 3 Erewash Community Occupational Therapy Service, Derbyshire 4 Computing and Technology Team, School of Science and Technology, Nottingham Trent University 5 Sherwood Forest Hospitals NHS Foundation Trust

2. Background • Need new approach to provide the necessary rehabilitation of upper limb following stroke. • Patients have decreasing access to appropriate therapy and even if sent home with exercises, adherence to treatment is poor. • Treatment programmes can appear rigid and inflexible. Their effectiveness is irrelevant if they exhaust patients’ capabilities and motivation (Clay and Hopps, 2003). • 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.

3. Background continued • Virtual reality and interactive video gaming have emerged as new treatment approaches in stroke rehabilitation (Laver et al, 2011). • Commercial gaming consoles already used in clinical settings (eg Saposnik et al 2010): advantages of mass acceptability, easily perceived feedback and affordability for unrestricted home use. But games not designed for therapeutic use and current systems do not capture movement of fingers. • In conjunction with users we developed a low cost intervention for home use that was flexible and motivating in order to improve adherence • Do patients actually use it to the recommended level and if not, why not?

4. Virtual glove • Virtual glove allows capture of position of thumb and three fingers and translates into game play. • Designed to facilitate practice of movements that underlie everyday tasks such as grasp and release • Currently carrying out a feasibility trial due to finish in 2013. • Examining data collected so far on participants who have currently completed the intervention to determine how close to the recommended duration and frequency they were using the glove.

5. Games: Speed race • Four games each with a different levels of challenge to keep the participants motivated to continue to use the system but to ensure that they can achieve some success. • Scores displayed on the screen at the end of a game. • A log of when the system is in use is collected by the computer as well as what games are being played and what scores the user obtains. Easiest game (speed race) practices wrist flexion

6. Space race Game most participants start on practices wrist rotation (pronation and supination). Forward movement provided and user must steer space ship through gaps in obstacles

7. Balloon pop Practices grasp and release: user must grasp balloon and move to pin to burst it

8. Sponge ball Practices grasp and release. User opens hand to release ball aimed to hit target

9. Feasibility trial Trial Participants • aged 18 or over • who have had a stroke • who are no longer receiving any other rehabilitation • who still have residual upper limb dysfunction. • Randomly allocated to either the intervention (virtual glove) group or the control group (usual care). • Intervention group has the virtual glove, games and a PC in their homes for a period of 8 weeks . • They are advised to use the system for 20 minutes 3 times a day (max 56 hours). • Baseline and follow up measures of upper limb function

10. Provision of support One of the biggest challenges to the evaluation is participant failure to adhere to the proposed frequency of use of the system. Support provided: • Demonstration to participant and their carer. • Phone calls from research team. • Visits from research team to retrieve data and check progress. • Leave phone number of member of research team

11. Participants 23 participants consented so far (8 so far allocated to intervention) • 79 year old woman. Lives alone. Finished with the Community Stroke Team so no other weekly appointments. Had started to drive again but wasn’t going anywhere most days. Slept in the afternoon. Has laptop but had not used it since her stroke as she could not manage the mouse pad. • 54 year old man. Has young children at school and spends a lot of time with them taking them to sporting activities. He has time in the day when the children are at school but attends a stroke exercise group on Fridays and has many other appointments. Experienced computer user and gamer, has Wii, Xbox and a laptop all of which are regularly used.

12. Participants cont. • 53 year old woman, 19 weeks post stroke dominant (right) upper limb affected. Lives alone. Was starting back at work for 4 hours twice a week. Only has the speech and language therapist visiting her at home now. She has a laptop at home which she uses regularly especially to email family. She was very motivated as she knew she only had the computer for 4 weeks due to her holidays • 76 year old woman, TIA Jan 2012. Lives with husband who has early dementia. Both use their own individual computers daily (eg games, emailing family). Better in the mornings, short 30 m sleep before lunch, or ends up sleeping for longer after lunch. Many equipment issues but mild ataxia in her hand and her natural thumb alignment may have caused issues with games.

13. Hours of use Hours of use Considerable variation between participants. No-one achieved 56 hours but P9 who had glove for only 4 weeks was not far off the recommended use.

14. Number of days in use Number of days in use Apart from the experienced gamer, participants were using the glove most days. Both P9 and P13 used the glove on every day it was with them

15. Median duration only for days when in use Even for participant number 9 the median duration is 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 days use exceeded the recommendation.

16. Pattern of play across the day

17. Barriers to use • Equipment outages. • Being dependent on someone to help. • If the participant is computer literate the games are likely to become boring: “I would say the first few weeks was brilliant. But as I say, then as it got going longer on, it was sort of, well, some days I couldn't be bothered and then some days, if you've got something else to do, it was just sort of missing it out. But at first, yes, it was really good.” (P8). • Other health problems • Competing commitments : “And what time the family came, if the family came just when I had started it – I had to then leave it” (P4) , and more passive pastimes: “I admit it depended what was on the telly” (P4). • Getting back to pre stroke life especially once mobile

18. Facilitators of use • Flexibility: “Whereas with a computer, you could say four o'clock/five 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) • Immersion in games “You just forget what – you sort of look at the time and, say it was ten o'clock, you're playing and then the next time you look up you think, crikey, it's half-past eleven, sort of thing.” (P8) • Belief in its therapeutic nature “Oh yeah, of course, because it helps – well, it helps you a lot in your movement. First and fore, with the position, you know, then you enjoy the games.” (P9)

19. Discussion • Pattern of play is variable and can fall far short of our recommendations. • Any increase in activity is beneficial. • This intervention is proving to provide required flexibility • Some thought the recommended time was fine, others thought it was too much. • participant with the lowest use thought he had reached the recommendations, whereas data indicated this was not the case. • Will not suit everyone but dangerous to make assumptions based on eg age or computer literacy. • Not an alternative to the hands on involvement of a therapist: it supplements the limited amount of time therapists have available for each patient.

20. Acknowledgements • The NIHR CLAHRC – NDL is a partnership between the University of Nottingham and local NHS organisations and is funded by the NIHR. • Thanks to our expert users for advice on running the trial • Colleagues at NTU including Andy Burton