By Ellen Feldman, MD
Altru Health System, Grand Forks, ND
• With a goal of developing a low-cost, effective, and safe telerehabilitation intervention for balance training in the early post-stroke period, this Chilean group recruited 10 patients from a physical therapy center.
• Six post-stroke patients received nine sessions of 30 min/week of the telemedicine intervention in addition to conventional hospital-based rehabilitation, while four patients made up the randomly selected control group (conventional treatment only).
• The intervention included specially designed exergames (activity-based video games) delivered via a conventional smartphone along with sensor monitoring and remote supervision.
• After four weeks, one measure of balance and a measure of functional independence showed significant improvement in the intervention group when compared with the control; a second measure of balance did not show significant difference between the groups.
SYNOPSIS: This small pilot study reveals potential for exergames (activity-based video games) to be used as a telemedicine rehabilitation intervention in improving balance and function in patients six to eight weeks post-stroke.
SOURCE: Burgos PI, Lara O, Lavado A, et al. Exergames and telerehabilitation on smartphones to improve balance in stroke patients. Brain Sci 2020;10:773.
Strokes leave more than one-half of survivors older than 65 years of age with reduced mobility. Rehabilitation is a standard practice to improve functional impairment associated with stroke. Typically, balance training is a later intervention, but recent studies suggest that addressing balance in early post-stroke periods may be safe and effective.1,2
Burgos et al noted that some health systems hesitate to use remote balance training interventions out of concern for fall risk in post-stroke patients. However, they noted growing literature in the field supporting the use of technology to check posture remotely and perhaps mitigate this risk. With a goal of developing a remote intervention for balance training in the early phases of the post-stroke period, this team devised a series of movements linked to a game (exergames) delivered via a conventional smartphone and sensors. Exergames generally are defined as technology-driven physical activities, such as video games, requiring body motion and physical movement to participate. While exergames such as Dance Dance Revolution and games for Microsoft’s Kinect initially were developed to motivate youth to become more active, there is exciting potential for use of this modality in other populations.3
Patients were recruited from two physical therapy rehabilitation centers in Santiago, Chile. Ten volunteers, six to eight weeks post-stroke, enrolled and qualified for the study. Each was randomly assigned to either the control or intervention group. Inclusion criteria for the study included having at least one caregiver at home and showing evidence of impaired balance (as measured on the Berg Balance Scale [BBS]).4 All study participants continued to receive standard rehabilitation (three sessions of 40 minutes weekly) at the physical therapy site throughout the four weeks of the study. The intervention group received additional remote balance training of nine 30-minute sessions weekly. These sessions used smartphone exergames to motivate and direct movement along with inertial movement sensors (IMU) designed to measure stability.
The study protocol included an initial balance assessment at the physical therapy site followed by a home visit where the participant and caregiver were trained on exercise safety and sensor placement and calibration. Six different exergames were introduced over the four weeks of the study. These games targeted balance improvement in multiple areas, including sit-to-stand, side-to-side, and front-to-back. The games also used music and dance aimed at improving anticipatory postural control. The games were designed to allow modification of difficulty as the participants progressed. With remote monitoring in place, an assigned physical therapist reviewed videos of games, kept in touch daily via phone, and problem-solved any technical difficulties. Several scales and tests were used to measure outcomes. The BBS and the Mini Balance Evaluation Systems Test (MBT) were employed to assess initial and final balance.5 The Barthel Index (BT) ranked the ease of performing activities of daily living (ADLs) and helped to determine functional independence.6 The System Usability Scale (SUS), a 10-item questionnaire regarding ease of use (higher scores reflect greater satisfaction), was used to evaluate participants’ user experience.7
Control and intervention group participants all showed improvement on both measures during the four weeks of the study. The difference between the intervention and control groups was significantly stronger as measured by the BBS, but not by the MBT:
- BBS: average improvement 20.20% ± 6.36 for the intervention group vs. 12.5% ± 8.63 (P = 0.019);
- MBT: average improvement 29.7% ± 10.75 for the intervention group vs. 16.96% ± 9.39 (P = 0.245).
Significant improvement in functional independence (BT score) was seen in the intervention vs. the control group: 17.50 ± 9.87 vs. 3.75 ± 8.53 (P = 0.025). Finally, the average SUS score was 87.5 (± 11.61), indicating high to excellent user satisfaction.
Burgos et al presented a pilot study regarding the efficacy and feasibility of enhancing rehabilitation efforts via remote intervention in the subacute phase of stroke recovery. Taking an innovative approach, this group demonstrates that a relatively low-cost solution using a conventional cell phone and sensors may have promise in delivering remote, individualized physical therapy.
There are many areas of this study that limit generalizability. Certainly, the low number of participants is a barrier to broad generalizations. Additionally, the lack of a sham control makes it difficult to fairly compare results between the intervention and control groups, since both groups continued to receive conventional rehabilitation. Given that the intervention group received significantly more rehabilitation minutes weekly, it may be that factors such as the frequency of intervention alone, scheduled time to focus on movement, or even scheduled interaction with a caregiver around movement was more significant than progression through the exergame series. Expanding the control group to include a physical activity with frequency matched for time to the active intervention can help in defining these relationships. No negative outcomes linked to the use of the exergames were described in this paper.
Future studies that investigate the limits and applicability of exergames (or similar remote physical therapy interventions) in specific populations will help clarify the usefulness and relative risk of these techniques. Finally, it is difficult to understand why one measure of balance (BBS) in the intervention group showed a significant improvement vs. control, while the other measure (MBT) did not show a significant difference. Further studies with larger number of participants are needed to more fully delineate the advantages and disadvantages of this type of remote intervention.
Interestingly, in 2019 another group (Arienti et al) published a meta-analysis covering 51 systematic reviews regarding interventions for balance improvement post-stroke. This team concluded that methodology in the majority of the studies was poor (only 22% of the studies were considered high quality), thus no firm conclusions could be drawn. Stroke is one of the main causes of long-term disability in the developed world; high quality, robust investigations in this field can help develop a path to lessen the effect of this neurological insult.
For now, the take-home message from this study is clear: technology has a role and future in medical practice. It is notable that Burgos et al adapted exergames — a technology developed primarily for youth — to a high-medical-risk older adult population. Thinking outside the box and broadening medical teams to include persons with expertise in technological fields may open new doors and encourage novel approaches.
A complete list of references can be found online at http://bit.ly/3tFEuD7.