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Background Approximately two thirds of stroke survivors maintain upper limb (UL) impairments and few among them attain complete UL recovery 6 months after stroke. Technological progress and gamification of interventions aim for better outcomes and constitute opportunities in self- and tele-rehabilitation. Objectives Our objective was to assess the efficacy of serious games, implemented on diverse technological systems, targeting UL recovery after stroke. In addition, we investigated whether adherence to neurorehabilitation principles influenced efficacy of games specifically designed for rehabilitation, regardless of the device used. Method This systematic review was conducted according to PRISMA guidelines (PROSPERO registration number: 156589). Two independent reviewers searched PubMed, EMBASE, SCOPUS and Cochrane Central Register of Controlled Trials for eligible randomized controlled trials (PEDro score ≥ 5). Meta-analysis, using a random effects model, was performed to compare effects of interventions using serious games, to conventional treatment, for UL rehabilitation in adult stroke patients. In addition, we conducted subgroup analysis, according to adherence of included studies to a consolidated set of 11 neurorehabilitation principles. Results Meta-analysis of 42 trials, including 1760 participants, showed better improvements in favor of interventions using serious games when compared to conventional therapies, regarding UL function (SMD = 0.47; 95% CI = 0.24 to 0.70; P  < 0.0001), activity (SMD = 0.25; 95% CI = 0.05 to 0.46; P  = 0.02) and participation (SMD = 0.66; 95% CI = 0.29 to 1.03; P  = 0.0005). Additionally, long term effect retention was observed for UL function (SMD = 0.42; 95% CI = 0.05 to 0.79; P  = 0.03). Interventions using serious games that complied with at least 8 neurorehabilitation principles showed better overall effects. Although heterogeneity levels remained moderate, results were little affected by changes in methods or outliers indicating robustness. Conclusion This meta-analysis showed that rehabilitation through serious games, targeting UL recovery after stroke, leads to better improvements, compared to conventional treatment, in three ICF-WHO components. Irrespective of the technological device used, higher adherence to a consolidated set of neurorehabilitation principles enhances efficacy of serious games. Future development of stroke-specific rehabilitation interventions should further take into consideration the consolidated set of neurorehabilitation principles.

Context: This review aimed to synthesize the literature on the acceptability, feasibility, and effectiveness of immersive virtual technologies to promote physical exercise in older people. Method: We performed a literature review, based on four databases (PubMed, CINAHL, Embase, and Scopus; last search: 30 January 2023). Eligible studies had to use immersive technology with participants aged 60 years and over. The results regarding acceptability, feasibility, and effectiveness of immersive technology-based interventions in older people were extracted. The standardized mean differences were then computed using a random model effect. Results: In total, 54 relevant studies (1853 participants) were identified through search strategies. Concerning the acceptability, most participants reported a pleasant experience and a desire to use the technology again. The average increase in the pre/post Simulator Sickness Questionnaire score was 0.43 in healthy subjects and 3.23 in subjects with neurological disorders, demonstrating this technology’s feasibility. Regarding the effectiveness, our meta-analysis showed a positive effect of the use of virtual reality technology on balance (SMD = 1.05; 95% CI: 0.75–1.36; p < 0.001) and gait outcomes (SMD = 0.7; 95% CI: 0.14–0.80; p < 0.001). However, these results suffered from inconsistency and the number of trials dealing with these outcomes remains low, calling for further studies. Conclusions: Virtual reality seems to be well accepted by older people and its use with this population is feasible. However, more studies are needed to conclude its effectiveness in promoting exercise in older people.

Objective:Executive functions (EFs) refer to a set of top-down cognitive processes that are fundamental for the control of goal directed behaviours (Lezak et al., 2004). Inhibition (the capacity to ignore irrelevant information) and selective attention (the capacity to selectively focus on relevant information) are considered as the core components of EFs (Barkley, 2001; Veer et al., 2017). EFs can be impaired following brain damage (Chung et al., 2013) and they are traditionally assessed individually, using paper-and-pencil tests that have long been criticized for their ecological and sensitivity limitations (Dugbartey et al., 1999; Miyake et al., 2000). Here we developed a serious game in immersive virtual reality to measure inhibition and selective attention based on the go/no-go paradigm and the D2 Test.Participants and Methods:Sixty healthy participants were asked to perform a series of tasks, where in each task, the target was a mole wearing a coloured helmet. In task A, either the target or a distractor bomb was presented. The participants had to respond to the target and inhibit a response to the bomb. In task B, the target was presented with distractor moles wearing different coloured helmets. The two tasks could also be combined, task AB, where the target was presented with distractors (as in task B) versus the bomb was presented with distractor moles. All the stimuli appeared from four molehills aligned to sagittal axis (near to far from the participant). Responses were made with the dominant hand in task A and with both tasks in tasks B and AB. The participants were instructed to hit the target with a virtual hammer.Results:Response time analysis showed that in tasks A, B and AB, participants were slower to respond to the far compared to near targets. In task B and AB, participants were additionally slower to respond to the left compared right targets. Significant interactions between laterality and proximity for tasks B and AB showed that the participants were significantly slower to response to left vs right target in both far and near conditions. All participants were able to inhibit responses to the bomb and distractor stimuli.Conclusions:In conclusion, we have developed a novel serious game in immersive virtual reality for the assessment of inhibition and selective attention, both as individual tests and as a combined test. Future studies will test patients with executive dysfunction to test the validity of this new serious game.

Objective:Stroke results in various cognitive and motor impairments. The most frequent cognitive problem is spatial and non-spatial attention, typically caused by unilateral brain lesion. Attention is typically assessed with several different paper-and-pencil tests, which have long been criticized for their lack of theoretical basis, their limited ecological validity to deficits experienced in daily life, and their lack of measurement sensitivity (Appelros et al., 2004; Azouvi, 2017). Here, our global aim was to develop an innovative integrative serious game in an immersive environment. The REASmash, combines the evaluation of spatial attention, non-spatial attention, and motor performance. We present the spatial and non-spatial cognitive attention evaluation results.Participants and Methods:Eighteen first stroke individuals and 40 age-match healthy controls were assessed on the REASmash. They were instructed to find a target mole presented amongst distractor moles. The stimulus array consisted of a grid of 6 columns and 4 rows of molehills, from which the target and 11, 17 and 23 distractors moles could randomly appear, in two search conditions (single feature condition and saliency condition). Responses were made with the ipsilesional hand for individuals with stroke and with the dominant hand for the healthy controls. Participants were evaluated also with two standardized clinical tests of attention; the hearts cancellation task of the Oxford Cognitive Screen, and the visual scanning subtest of the Test for Attentional Performance.Results:Validation results showed significant and strong correlations between the REASmash and the two reference tests, with the REASmash showing high sensitivity and specificity (i.e., the correct identification of the post-stroke vs. control individuals). The REASmash also showed significant and strong test/re-test reliability. We additionally evaluated user experience using the UEQ, and the results showed excellent attractiveness and novelty, and good stimulation and efficiency.Conclusions:In conclusion, the REASmash is a novel immersive virtual environment serious game that is valid, sensitive, and usable. It provides a new diagnosis measure spatial and non-spatial attention impairment.

Although guidelines are established for performing the six-minute walking test (6MWT), it is not always possible to implement this test in any setting, due to physical and space limitations. Yet, variations in the conditions of the test could be responsible for heterogeneous outcomes. However, the impact of the condition of the 6MWT is not clearly established in literature. The objective is to determine the influence of different implementation conditions on the validity of the 6MWT. Seventeen articles were retained after a literature review, including 597 participants. Seven articles mention that performing the test on a predetermined short back-and-forth pathway led to lower performance than when the test was performed on pathways of greater distances. The walking distance covered on a rectangular path or on a 10-m eight-form path is greater than with the back and forth on a five- to ten-meter path. Seven articles suggest that the performance achieved on a treadmill is generally lower than that obtained while walking on the ground. Evidence shows that the conditions while performing the 6MWT significantly influence the score, hence the validity of the results. The use of a ground pathway, comprising the longest linear distance possible, seems critical to ensure good validity.

Background After a stroke, experts recommend regular monitoring and kinematic assessments of patients to objectively measure motor recovery. With the rise of new technologies and increasing needs for neurorehabilitation, an interest in virtual reality has emerged. In this context, we have developed an immersive virtual reality version of the Box and Block Test (BBT-VR). The aim of this study was to assess the concurrent validity of the BBT-VR among patients with stroke and healthy participants. Methods Twenty-three healthy participants and 22 patients with stroke were asked to perform the classical Box and Block Test (BBT) and BBT-VR three times with both hands. Concurrent validity was assessed through correlations between these two tests and reliability of the BBT-VR through correlation on test–retest. Usability of the BBT-VR was also evaluated with the System Usability Scale. Hand kinematic data extracted from controller’s 3D position allowed to compute mean velocity (V mean ), peak velocity (V peak ) and smoothness (SPARC). Results Results showed strong correlations between the number of blocks displaced with the BBT and the BBT-VR among patients with stroke for affected (r = 0.89; p < 0.001) and less-affected hands (r = 0.76; p < 0.001) and healthy participants for dominant (r = 0.58; p < 0.01) and non-dominant hands (r = 0.68; p < 0.001). Reliability for test–retest was excellent (ICC > 0.8; p < 0.001) and usability almost excellent ( System Usability Scale  = 79 ± 12.34%). On average participants moved between 30 and 40% less blocks during the BBT-VR than during the BBT. Healthy participants demonstrated significantly higher kinematic measures (V mean  = 0.22 ± 0.086 ms −1 ; V peak  = 0.96 ± 0.341 ms −1 ; SPARC = − 3.31 ± 0.862) than patients with stroke (V mean  = 0.12 ± 0.052 ms −1 ; V peak  = 0.60 ± 0.202 ms −1 ; SPARC = − 5.04[− 7.050 to − 3.682]). Conclusion The BBT-VR is a usable, valid and reliable test to assess manual dexterity, providing kinematic parameters, in a population of patients with stroke and healthy participants. Trial registration http://www.clinicaltrials.gov ; Unique identifier: NCT04694833, Date of registration: 11/24/2020

Background Recent technological advancements present promising opportunities to enhance the frequency and objectivity of functional assessments, aligning with recent stroke rehabilitation guidelines. Within this framework, we designed and adapted different manual dexterity tests in extended reality (XR), using immersive virtual reality (VR) with controllers (BBT-VR-C), immersive VR with hand-tracking (BBT-VR-HT), and mixed-reality (MD-MR). Objective This study primarily aimed to assess and compare the validity of the BBT-VR-C, BBT-VR-HT and MD-MR to assess post-stroke manual dexterity. Secondary objectives were to evaluate reliability, usability and to define arm kinematics measures. Methods A sample of 21 healthy control participants (HCP) and 21 stroke individuals with hemiparesis (IHP) completed three trials of the traditional BBT, the BBT-VR-C, BBT-VR-HT and MD-MR. Content validity of the different tests were evaluated by asking five healthcare professionals to rate the difficulty of performing each test in comparison to the traditional BBT. Convergent validity was evaluated through correlations between the scores of the traditional BBT and the XR tests. Test-retest reliability was assessed through correlations between the second and third trial and usability was assessed using the System Usability Scale (SUS). Lastly, upper limb movement smoothness (SPARC) was compared between IHP and HCP for both BBT-VR test versions. Results For content validity, healthcare professionals rated the BBT-VR-HT (0[0–1]) and BBT-MR (0[0–1]) as equally difficult to the traditional BBT, whereas they rated BBT-VR-C as more difficult than the traditional BBT (1[0–2]). For IHP convergent validity, the Pearson tests demonstrated larger correlations between the scores of BBT and BBT-VR-HT ( r  = 0.94; p  < 0.001), and BBT and MD-MR ( r  = 0.95; p  < 0.001) than BBT and BBT-VR-C ( r  = 0.65; p  = 0.001). BBT-VR-HT and MD-MR usability were both rated as excellent, with median SUS scores of 83[57.5–91.3] and 83[53.8–92.5] respectively. Excellent reliability was found for the BBT-VR-C (ICC = 0.96; p  < 0.001), BBT-VR-HT (ICC = 0.96; p  < 0.001) and BBT-MR (ICC = 0.99; p  < 0.001). The usability of the BBT-VR-C was rated as good with a median SUS of 70[43.8–83.8]. Upper limb movements of HCP were significantly smoother than for IHP when completing either the BBT-VR-C (t = 2.05; p  = 0.043) and the BBT-VR-HT (t = 5.21; p  < 0.001). Conclusion The different XR manual tests are valid, short-term reliable and usable tools to assess post-stroke manual dexterity. Trial registration https://clinicaltrials.gov/ct2/show/NCT04694833 ; Unique identifier: NCT04694833, Date of registration: 11/24/2020.

Background To plan treatment and measure post-stroke recovery, frequent and time-bounded functional assessments are recommended. With increasing needs for neurorehabilitation advances, new technology based methods, such as virtual reality (VR) have emerged. Here, we developed an immersive VR version of the Action Research Arm Test (ARAT-VR) to complement neurorehabilitation. Objective This study aimed to assess the validity, usability and test–retest reliability of the ARAT-VR among individuals with stroke, healthcare professionals and healthy control subjects (HCS). Methods Among the 19 items of the ARAT, 13 items were selected and developed in immersive VR. 11 healthcare professionals, 30 individuals with stroke, and 25 HCS were recruited. Content validity was assessed by asking healthcare professionals to rate the difficulty of performing each item of the ARAT-VR in comparison to the classical Action Research Arm Test (ARAT-19). Concurrent validity was first measured using correlation (Spearman tests) between the ARAT-VR and ARAT-19 scores for the individuals with stroke, and second through correlation and comparison between the scores of the ARAT-VR and the reduced version of the ARAT (ARAT-13) for both individuals with stroke and HCS (Wilcoxon signed rank tests and Bland–Altman plots). Usability was measured using the System Usability Scale. A part of individuals with stroke and HCS were re-tested following a convenient delay to measure test–retest reliability (Intra-class correlation and Wilcoxon tests). Results Regarding the content validity, median difficulty of the 13 ARAT-VR items (0[0 to − 1] to 0[0–1]) evaluated by healthcare professionals was rated as equivalent to the classical ARAT for all tasks except those involving the marbles. For these, the difficulty was rated as superior to the real tasks (1[0–1] when pinching with the thumb-index and thumb-middle fingers, and 1[0–2] when pinching with thumb-ring finger). Regarding the concurrent validity, for paretic hand scores, there were strong correlations between the ARAT-VR and ARAT-13 (r = 0.84), and between the ARAT-VR and ARAT-19 (r = 0.83). Usability (SUS = 82.5[75–90]) and test–retest reliability (ICC = 0.99; p < 0.001) were excellent. Conclusion The ARAT-VR is a valid, usable and reliable tool that can be used to assess upper limb activity among individuals with stroke, providing potential to increase assessment frequency, remote evaluation, and improve neurorehabilitation. Trial registration https://clinicaltrials.gov/ct2/show/NCT04694833 ; Unique identifier: NCT04694833, Date of registration: 11/24/2020.

Background Virtual Reality (VR) Serious Games (SGs) can provide a functionally relevant framework to capture cognitive and motor dynamics. Their interactive and engaging nature improves compliance, measurement reliability and allows for more frequent evaluations. Additionally, VR SGs enable the parallel collection of multiple types of data within a single session. We present REAsmash-ET, an immersive VR adaptation of the REAsmash SG, grounded in Feature Integration Theory (FIT) and integrating eye-tracking (ET) and upper limb kinematic (UL) analyses. REAsmash-ET introduces a novel methodological framework for the simultaneous assessment of attentional and motor functions in VR. Methods REAsmash is an interactive search-and-reach task designed to elicit structured visual exploration and UL motor responses under varying target-distractor saliency conditions. Custom algorithms extract metrics on visual search strategies and UL motor efficiency. Three age groups of adult healthy participants (n = 15 each) were included to test the feasibility and methodological consistency of the task and its metrics. Relative Response Time (RRT) and ET metrics were analyzed using ANOVA with factors: age group (20–39, 40–59, 60–80 years), target-distractor saliency (high vs. low), and number of distractors (11, 17, 23). Kinematic metrics were analyzed by age group and response hand (dominant vs. non-dominant). Results REAsmash-ET differentiated visuomotor performance across task conditions. RRT and ET metrics showed significant effects of saliency, number of distractors, and their interaction, consistent with FIT. Age-related differences emerged in both RRT and visual search efficiency. Kinematic analyses revealed slower and less efficient movements in older participants, with effects of hand dominance.. The results support the robustness and feasibility of REAsmash-ET as a methodological framework. Conclusions The results support the robustness and internal consistency of REAsmash-ET as a methodological framework for the integrated assessment of visual attention and UL motor control in immersive VR. The task’s ability to capture visuomotor variability and its multidimensional approach highlight its potential for future research and clinical applications in both healthy and clinical populations. Registry number This study was registered at ClinicalTrials.gov (NCT04694833).

Background: The use of standardised assessment tools is a fundamental aspect of good clinical practice. However, to our knowledge, no study has documented the use of standardised assessment tools in physiotherapy in French-speaking sub-Saharan Africa.Objectives: Documenting the use of standardised outcome measures in physiotherapy in French-speaking sub-Saharan Africa.Method: Our cross-sectional survey used an online self-questionnaire on facilitators and barriers to the use of standardised outcome measures, distributed to physiotherapists in French-speaking sub-Saharan Africa.Results: A total of 241 physiotherapists working in French-speaking sub-Saharan Africa responded to the survey. The most represented countries were Benin (36.9%), Cameroon (14.1%), and Burkina Faso (10.8%). Although 99% of participants reported using standardised outcome measures, only 27% of the respondents used them systematically (all the time). The most reported facilitators included the recognition that standardised outcome measures help to determine whether treatment is effective, help to guide care, and improve communication with patients. The most significant barriers were the lack of time, unavailability of the standardised outcome measures, and non-sensitivity of measures to patients’ cultural and ethnic concerns. There was a higher proportion of use in the middle age group (30–40) (p = 0.02) and a lower proportion of use in physiotherapists simultaneously working in public and private sectors (p = 0.05).Conclusion: Standardised outcome measures are still not widely used by physiotherapists in French-speaking sub-Saharan Africa.Clinical implications: The perceived barriers and facilitators could help to develop strategies to improve the systematic use of outcome measures in French-speaking sub-Saharan Africa.