Did you know 60% of stroke survivors have residual disabilities after rehabilitation? Participating in intensive therapist-guided rehabilitation is one way to combat such disabilities. Multiple studies show that increasing repetition of exercises will aid in recovering the lost functions post stroke. However, limiting factors such as insufficient staffing, poor compliance, and motivation of stroke survivor can affect the efficacy of intensive therapist-guided rehabilitation. To combat this, many companies and researchers turn to the development of rehabilitative technologies to target such problems.

During my clinical practice education (CPE) I had firsthand experience in witnessing the shortage of manpower in the healthcare industry. In addition, with the debilitating effects of stroke on mobility functions, patients may not be participative in therapy secondary to feeling an acute sense of loss and grieving their loss in function. As an avid gamer, I have always been interested in technology and often wonder about the impact of incorporating technology with rehabilitation. Indeed, rehabilitative technology such as virtual reality gaming may help in increasing patient compliance to therapy by providing an interesting approach in engaging the patients.

Hence, it is important to be able to accurately and quickly assess if the stroke survivor or therapist will uptake such rehabilitative technology to aid in therapy. It is also imperative to identify and understand the constructs that influence the uptake of rehabilitative technology. With the help of our Honours Thesis Supervisor Assistant Professor Choo Pei Ling (Principal Investigator) and the help of two other Physiotherapy classmates, this was what our research study aimed to answer before developing a novel User Satisfaction of Rehabilitation Therapy Questionnaire (USRTQ).

About the study

We sought to undertake this research in three steps- item generation, theoretical analysis, and psychometric analysis. In the item generation phase, the team sought to find out constructs with which user satisfaction is measured. Theoretical and psychometric analysis were done in two parts, decision criteria to keep individual items and decision-making for inclusion or exclusion of items.

Our research team found that the constructs of user satisfaction consisted of product design, intrinsic motivation, feasibility (i.e., user interface) and safety. We also discover that existing tools only seek to assess some elements of these constructs. Through a series of consultations with experienced clinicians, our team came to a general consensus that the most important constructs of user satisfaction comprise fun, engagement, usability, and perceived therapeutic benefits.

The validation of USRTQ required a trial use of rehabilitation technology and Armeo®Senso was used. Armeo®Senso is an inertial measurement unit-based upper limb (UL) rehabilitation training technology produced by Hocoma (2021). It integrates virtual reality gaming to maximize patient engagement in therapy and promotes active participation through self-directed home therapy while at the same time monitoring improvements of UL functions and giving performance feedback reducing the need for face-to-face therapy supervision.

Recruiting 38 participants, including a subset of stroke survivors, the team put the participants through a series of games at various gaming difficulty with the Armeo®Senso. They would answer questions from existing tools as well as from the newly developed USRTQ for validation. Through this process, the team found that USRTQ was found to be an acceptable, valid and internally consistent outcome measure of user satisfaction of rehabilitative technology.

Besides that, FysioRoadmap, an electronic patient software program, ensures the best possible quality standards for all different training goals and indications. FysioRoadmap consists of predefined training protocols and multiple assessments and reporting options to increase effectiveness for clients and therapists.

Omring has over 30 locations in the Netherlands. Omring Lindendael is one of their three locations using the DIH devices and is a center for geriatric healthcare that currently represents the home for 170 residents. Omring continues to distinguish itself as an innovative and progressive organization, while providing advanced technology solutions for patients and health care professionals.

Pictures above show the research team during the home visit with stroke survivors using the Armeo®Senso and playing games.

Interesting findings

During the study, two stroke survivor participants shared that they felt motivated while using the virtual reality gaming device. As their upper limb function had been impacted due to the stroke, they felt empowered when they saw the cursor moving the way they wanted to. Intrinsic motivation is an important construct of user validity – This is hopeful for the progression and adoption of rehabilitative technology.

Surprisingly, our study also found that games do not really follow an age category. For example, one would think that university students would be more attracted to shooting games or games with more action on the screen. However, each game has a certain number of people who are interested in the game. This shows how diverse gaming engagement is for the general public. It may be difficult to make just one game as it may become repetitive and eventually boring for the patient to keep playing the same game.

Another interesting fact is that dimensions that are thought to be different, namely “fun” and “engagement”, were loaded into the same factor in the factor analysis. The current research has established that both factors are similar, have specific interconnections and are put in the same dimension as engagement.

The next step is for further validation work with the USRTQ. This study also shows the next step towards virtual reality gaming, whereby we should have a wide variety of games to pander to the interests of people from all walks of life.

SIT Research Team – Assistant Professor Choo Pei Ling, Principal Investigator; SIT Physiotherapy students Darren Low Jun Xian, Low Qi Long Chester and Ng Wei Ling Sonia.