This document summarizes a study examining adherence to a home-based virtual reality rehabilitation system for the upper limb following stroke. The study found that adherence varied considerably between participants, with no one achieving the recommended 56 hours of use but some coming close. Most participants used the system on multiple days, though median daily durations were often less than an hour. Barriers to use included equipment outages, lack of computer literacy, and competing commitments. Facilitators included the flexibility of the system and immersion in the games. The findings suggest such systems can increase activity levels but may not replace therapist involvement.

1. Research making a difference to practice
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:
•Demonstrations 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
27 participants consented so far
• 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