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- Hindawi Publishing Corporation
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- Copyright © 2019 Carmen Nélida Waliño-Paniagua et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
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- 2040-2295
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- 2040-2309
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- 10.1155/2019/9780587
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Abstract
Hindawi Journal of Healthcare Engineering Volume 2019, Article ID 9780587, 7 pages https://doi.org/10.1155/2019/9780587 Clinical Study Effects of a Game-Based Virtual Reality Video Capture Training Program Plus Occupational Therapy on Manual Dexterity in Patients with Multiple Sclerosis: A Randomized Controlled Trial 1 1 Carmen Ne´lida Waliño-Paniagua, Cristina Go´mez-Calero , 2 3 4 Marı´a Isabel Jime´nez-Trujillo, Leticia Aguirre-Tejedor, Alberto Bermejo-Franco, 5 1 Rosa Marı´a Ortiz-Gutie´rrez, and Roberto Cano-de-la-Cuerda Department of Physiotherapy, Occupational erapy, Rehabilitation and Physical Medicine, Health Sciences Faculty, Universidad Rey Juan Carlos, Alcorcon, Madrid, Spain Department of Medicine and Surgery, Psychology, Preventive Medicine and Public Health and Medical Microbiology and Immunology, Nursing and Stomatology, Faculty of Health Sciences, Universidad Rey Juan Carlos, Alcorco´n, Madrid, Spain Occupational erapy Unit, Asociacio´n Mostoleña de Esclerosis Mu ´ltiple (AMDEM), Mo´stoles, Madrid, Spain Servicio de Rehabilitacio´n, Hospital Universitario Ramo´n y Cajal, Madrid, Spain Department of Physiotherapy, Centro de Estudios Universitarios San Rafael–Nebrija, Madrid, Spain Correspondence should be addressed to Roberto Cano-de-la-Cuerda; roberto.cano@urjc.es Received 30 January 2019; Accepted 21 March 2019; Published 22 April 2019 Guest Editor: Antoni Jaume-i-Capo´ Copyright ©2019 CarmenNe´lida Waliño-Paniaguaetal.,is isan openaccessarticledistributedunder theCreativeCommons AttributionLicense,whichpermitsunrestricteduse,distribution,andreproductioninanymedium,providedtheoriginalworkis properly cited. Neurorehabilitation is a fundamental aspect in the treatment approach for multiple sclerosis (MS), in which new technologies have gained popularity,especially theuse of virtualreality (VR).,e aim of thispaper isto analyze anoccupationaltherapy (OT) intervention compared with OT+VR (OT+VR) on the manual dexterity of patients with MS. 26 MS subjects were initially recruited from an MS patient association and randomized into two groups. ,e OTgroup received 20 conventional OTsessions distributed in two sessions per week. ,e OT+VR group received 20 sessions of VR interventions, twice weekly and lasting 30minutes, consisting of VR games accessed via the online web page motiongamingconsole.com, in addition tothe conventional OTsessions. Pre- and postintervention assessments were based on the Purdue Pegboard Test, the Jebsen-Taylor Hand Function Test, and the Grooved Pegboard Test. Clinical improvements were found regarding the precision of movements, the execution times,andtheefficiencyofcertainfunctionaltasksinthePurduePegboardTestandJebsen-TaylorHandFunctionTesttestsinthe OT+VR group. Although significant differences were not found in the manual dexterity between the OTand OT+VR groups, improvements were found regarding the precision and effectiveness of certain functional tasks. spasticity, cognitive and emotional disorders, speech dis- 1. Introduction orders, problems affecting the bladder and intestines, and Multiple sclerosis (MS) is a chronic inflammatory de- sexual-related dysfunction [2]. myelinating illness of the central nervous system (CNS) of Different disease courses exist for MS, according to the unknown etiology, currently representing the most com- appearance of symptoms, characterized by relapses or flare- mon neurological illness causing disability among young ups, which vary from one episode to the other, according adults in Europe and North America [1]. Common to the affected CNS region. ,e different types of MS in- symptoms include fatigue, visual disorders, problems af- clude relapsing-remitting MS, primary progressive MS, fecting balance and coordination, sensitivity disorders, secondary-progressive MS, and progressive-recurrent MS 2 Journal of Healthcare Engineering [3]. Relapsing-remitting MS is the most common form of moved); as well as a score of four points or less in the MS, whereas progressive-recurrent MS is the least common “Pyramidal Function” section of the EDSS functional scale; absence of cognitive decline; with the ability to understand type of illness. ,e treatment of MS commonly features both phar- instructionsandobtainingascoreof24ormoreintheMini- macological and rehabilitation treatments. Rehabilitation Mental Test; and a score of two points or less in the “Mental programs can increase the effectiveness of pharmacological Functions” section of the EDSS. treatment by providing symptomatic treatment of MS to ,e exclusion criteria were a diagnosis of another improve the quality of life and functional independence of neurological illness or musculoskeletal disorder different to affected individuals. ,e main therapeutic demands are the MS; the diagnosis of a cardiovascular, respiratory, or met- alterations of postural control and the performance of ac- abolic illness or other conditions which may interfere with tivities of daily living (ADLs) [4–6]. Occupational therapy the study; suffering a flare-up or hospitalization in the last (OT) evaluates the capacities and physical, psychological, three months prior to commencement of the assessment sensory and social problems of individuals with MS, to protocol or during the process of the therapeutic in- tervention; receiving a cycle of steroids, either intravenously support their independence in daily living and/or to facil- itate adaptation to their disability [7]. or oral, six months prior to the commencement of the as- At times, rehabilitation treatments for patients with MS sessment protocol and within the study period of in- can be very lengthy and systematic, leading to loss of mo- tervention; receiving treatment with botulinum toxin in the tivation and compliance. As a result, in recent years, new six months prior to the beginning of the study; or the intervention strategies have been introduced, such as virtual presenceofvisualdisordersnoncorrectedbyopticaldevices. reality (VR), thanks to VR motion capture technology, Allparticipatingsubjectsvoluntarilysignedaninformed without requiring a device or controller. ,ese novel ap- consent form. ,e present study was approved by the Re- proaches enhance patient motivation by enabling the search Ethics Committee of the Rey Juan Carlos University practice of functional tasks in virtual surroundings, pro- (Ref 26/12). viding patient feedback concerning results, all of which is based on the repetition of ADLs. ,us, rehabilitation pro- 2.2. Participants. Twenty-six subjects with relapsing- fessionals have expanded the care of patients with MS, by remitting MS were initially recruited and randomized into including this technology as a complement to rehabilitation two groups by tossing a coin. ,ereafter, 10 subjects could programs, achieving a higher treatment intensity at a sus- not complete the study due to relapses or noncompliance tainable cost [8]. However, few studies exist on the effects withthetreatmentprogram.Finally,thecontrolgroup(OT) that VR has on the manual dexterity of patients with MS comprised eight participants (n � 8), and the experimental [9–11]. ,us, the aim of this study was to analyze the effects group (OT+VR) also comprised eight participants (n � 8) of an OT intervention combined with VR on manual skills, (Figure 1). compared with conventional OTapproaches in people with MS. 2.3. Intervention. Conventional OT treatment consisted of 20 sessions during which subjects performed activities for 2. Methods training manipulative and functional dexterity of the upper limb aimed at ADLs. ,ese were distributed in two OT 2.1. Study Design. We conducted a single-blinded ran- domized controlled trial (RCT). Nonprobabilistic sampling sessions per week, each lasting 30minutes. ,e intervention applied to the experimental group ofconsecutivecaseswasused.,esamplewasdividedintoa control group (OT) who received conventional OT treat- consisted of 20 sessions of conventional OT distributed in ment and an experimental group (OT+VR) who received twosessionsperweek,eachlasting30minutes.Additionally, VR treatment in addition to their conventional treatment they received 20 treatment sessions lasting 20minutes, sessions. All interventions were performed at the Mostoleña twice weekly of VR via the online and free website Association of Multiple Sclerosis (AMDEM) in Madrid motiongamingconsole.com, during which they performed (Spain). exercises with video capture of the upper limb movements via the performance of functional and manual dexterity ,e study inclusion criteria were as follows: a diagnosis of MS according to the McDonald criteria [2] with over two activities based on the following games: Flip Out, Air Hockey, Particles, DunkIt, Counting Fish, and Robo Maro. yearsevolution;ascoreofbetween3.5(moderateincapacity, although totally ambulant, self-sufficient, and active during ,ere were not used a hand controller or armbands. All 12hours/day) and 6 (requires constant help, either unilat- exercises were designed to promote specific practice of erally or intermittently with a walking stick or crutches, in movements in the shoulder, elbow, wrist, and/or hand order to walk approximately 100meters with, or without, a through games displayed on a computer. OT+VR sessions rest) on the Kurtzke Expanded Disability Status Scale included leisure activities such as playing cards, hitting a (EDSS); with stable medical treatment during at least the six hockey puck, moving particles through a virtual scenario avoiding colliding with other elements, fishing, and playing months prior to the intervention; muscle tone in the upper limbsnotgreaterthantwopointsonthemodifiedAshworth “Jenga”. Patients were instructed to remain in a sitting position and use both upper limbs in these activities. All Scale (moderate hypertonia, increased muscle tone through most of the range of movement, but affected part easily tasks present a timer as a visual feedback. Journal of Healthcare Engineering 3 Enrollment Assessed for eligibility (n = 26) Randomized (n = 26) Allocation Allocated to intervention (n = 13) Allocated to intervention (n = 13) (i) Received OT intervention (i) Received OT + VR intervention Analysis Analysed (n =8) Analysed (n =8) (i) Excluded from analysis (noncompliance (i) Excluded from analysis (relapses) (n =5) with the treatment program) (n =5) Figure 1: Flowchart diagram. All OT and OT+VR interventions were performed by moving large light objects, and moving large heavy two occupational therapists, one for each modality, experts objects. on MS neurorehabilitation. All interventions considered the All the subtests are performed with the nondominant level of fatigue experimented by each patient based on a hand first, followed by the dominant hand. ,e time the progressive increase in treatment times according to the subject takes to perform each subtest is recorded. same. ,e Grooved Pegboard Test (GPT) [15] is a test that evaluates manipulative dexterity. ,is test is performedwith thedominanthandandconsistsofinsertingpegsintheslots 2.4. Outcome Measures. All assessments were performed by of a board which are placed at different angles. ,e score is physical therapists trained in the use of the measures and the time in seconds required for inserting all the pegs [16]. blinded to the intervention received by the subjects. ,e All the data were introduced into the SPSS v.17.0 sta- followingoutcomemeasureswereusedinbothgroups,both tistical package. A descriptive analysis of the quantitative at the beginning and at the end of the intervention. variables was performed using measures of central tendency ,e Purdue Pegboard Test(PPT)[12,13]wasusedforthe and dispersion measures: mean±standard deviation (SD) assessment of fine manual dexterity, gross dexterity, and and range. ,e pre-post comparison of each group and the coordination. ,is test evaluates the speed and motor comparisons between the control and experimental group dexterity of each hand and the manual dexterity using both were performed via the nonparametric Wilcoxon and hands at the same time. ,e PPTfeatures a board with two Mann–Whitney U tests, respectively, as the data did not columns with 25 holes each and a specific number of pins, follow a normal distribution. ,e level of statistical signif- washers, and collars placed in four containers across the top icance was set at p<0.05. of the board. ,e test consists of inserting as many pins as possible in three distinct phases, with a time limit of 3. Results 30seconds for each part.First, the test is performedwith the dominant hand, then with the nondominant hand, and then 16 patients (8males and 8females) successfully completed with both hands at the same time. ,e number of pins the study. ,e mean age of subjects was 46.44years (SD inserted is recorded. 9.09). Concretely, in the control group (4males and ,e Jebsen-Taylor Hand Function Test (JTT) [14] was 4females), the mean age was 46.13years (SD 9.49), and in used to determine the hand’s functional capacity. ,is the experimental group (4males and 4females), it was test is timed and divided in seven parts. ,e seven 46.75years (SD 9.31). ,e age range in the OT group was subtests are writing, page turning, picking up small 32–61years, and in the OT+VR group, it was 33–62years. common objects, simulated feeding, stacking checkers, For the totality of the sample, the dominant hand was the 4 Journal of Healthcare Engineering right in 62.5% of subjects. Regarding change in dominance 4. Discussion (patients who had to change their dominance to the other Ourfindingsrevealthatsignificantdifferencesdonotexistin hand due to impairment), in 25%, the dominant hand prior thetreatmentofmanualdexterityinsubjectsperformingthe to the appearance of MS was the left, and for 75% of the sample, it was the right. OT+VR intervention when compared to those receiving conventional OT treatment. However, statistically signifi- Participants from both study groups attended 100% of the proposed sessions in both protocols. No adverse effects cant differences were found in items such as “Picking up small common objects” using the nondominant hand and were registered. the dominant hand, with a tendency towards statistical significanceinthecaseof“Numberofcorrectlyplacedpegs” 3.1. Intragroup Pre-Post Comparison. Regardingthepre-post intheOT+VRgroup.Furthermore,severalvariablesrelated intervention data for the PPT, in the case of the control to effectiveness and motor dexterity also showed a tendency towards statistical significance in both groups. group (Table 1), a greater number of total pins were reg- istered in the postintervention assessment, although statis- RegardingtheconventionalOTintervention,statistically tically significant data were not obtained (p>0.05). significant differences were observed in the JTT test for the Regarding the differences in the JTT in the control group following items: “Writing” in the nondominant hand and (Table 2), statistically significant differences were found “Picking up small objects” with the dominant hand. To our regarding “Writing with the nondominant hand” knowledge,thisstudyisthefirsttoevaluatemanualdexterity (p � 0.018) and “Picking up small common objects with the in a population of MS, using the JTT. ,e results obtained dominant hand” (p � 0.012). Besides, improvements were may be due to the therapeutic approach of OT in patients observed regarding the execution time of tasks, although with MS, based on the performance of functional activities these values did not reach the level of statistical significance with the upper limb, as well as training the change in hand (Table 2). On the contrary, in the GPT, the control group dominance to enable a greater participation in ADLs [3]. Concerning the combined OT+VR interventions, the increased the final mean scores in the number of correctly placedpiecesusingthedominantandnondominanthand,as number of pins inserted between the initial and final as- well as the execution time and the number of pieces picked sessments was maintained in the PPTtest. Gallus et al. [17] up and placed with the dominant hand, although these identified the PPT as a valid measure for evaluating fine values did not reach statistical significance (Table 3). motricity and gross coordination in people with MS. In the Table 1 shows the PPTpre-post intervention scores for JTT test, significant changes were observed in the tests theexperimentalgroup.Aslightdecreaseinthenumberof “Picking up small common objects” with the dominant and inserted pins was observed; however, the results do not nondominant hand, as well as a tendency towards statistical appear statistically significant. Table 2 displays the pre- significance in the “Page turning” item. In the GPT test, improvements that were close to statistical significance were post intervention data for the JTT test obtained by the experimental group. Statistically significant changes were found in the number of correctly placed items. Possibly, the limitation of the sample size may have influenced these foundinthetasks“Pickingupsmallcommonobjects”with the nondominant hand (p � 0.036) and the dominant results. In the scientific literature, we were unable to find hand (p � 0.017). A tendency towards statistical signifi- studiesrelatedwiththeassessmentofmotordexterityviathe cance was observed for the task “Page turning” with the application of the JTT and the GPT in people with MS. dominant hand. Table 3 features the pre-post intervention However, Lozano et al. [11] used the JTT in people with data for the GPT test in the experimental group. Statis- brain damage, finding a clinical and significant improve- tically significant differences were found in the item ment in the performance of daily functional tasks such as “number of correctly placed pegs” with the nondominant “Page turning” and “Picking up small common objects”, hand(p � 0.078).Furthermore,improvementswere found using low-cost virtual reality surroundings with video captureof movementusingtheKinectsystem.,eresultsof in the times of the nondominant hand at the end of the intervention; however, these results were not significant the cited study coincide with our findings based on a free online games platform used in which the upper limb (p>0.05). Also, there was an increase in the correct placement of pegs and in the number of pegs fallen and movements of patients with MS were registered during the placed with both hands, without this being statistically performance of functional tasks. Given the context of our significant. study, taking place at a patient association, the online platform may be interesting for situations in which there may be insufficient economic resources to enable the ac- 3.2. Intergroup Pre-Post Intervention Comparisons. ,e in- quisition of new equipment. On the contrary, Merians et al. tergroup comparisons for the PPT revealed no statistically [18] also used the JTTto evaluate the fine motor dexterity of significant differences (p>0.05) (Table 1). Table 2 displays patients with brain damage as a measure of results after the the intergroup comparisons for the JTT. No statistically VR intervention, finding clinical improvements in the significant differences were found for any of the variables speed and precision of fine movements, and in some sub- (p>0.05) (Table 2). ,e intergroup comparison of the GPT jects,apost-interventiongeneralizationoflearningtoADLs. also failed to reveal statistically significant results (p>0.05) ,ese data are in line with our findings, in which clini- (Table 3). cal improvements existed, without achieving statistical Journal of Healthcare Engineering 5 Table 1: Differences pre-post intervention in Purdue Pegboard Test (PPT) in the control group and experimental group. OT OT+VR PPT p Pretreatment Posttreatment Pretreatment Posttreatment p p Mean±SD Mean±SD Mean±SD Mean±SD DH 6.25±3.65 7.50±4.07 0.319 7.50±4.07 7.37±3.37 0.792 0.832 NDH 5.25±3.57 4.00±2.56 0.263 4.00±2.56 4.25±2.25 0.48 0.707 Bilateral 3.54±2.11 3.62±1.99 1 3.62±1.99 3.37±2.06 0.577 0.665 Assemble 2.57±1.27 3.00±1.63 0.518 3.00±1.63 2.50±2.22 0.785 0.448 Total number of pins 17.61 18.12 0.898 18.12 17.49 0.602 DH: dominant hand; NDH: nondominant hand. Time in seconds. Table 2: Differences pre-post intervention in Jebsen-Taylor Hand Function Test (JTT) in the control group and experimental group. OT OT+VR JTT p Pretreatment Posttreatment Pretreatment Posttreatment p p Mean±SD Mean±SD Mean±SD Mean±SD Writing NDH (time) 93.25±73.68 62.92±42.92 0.018 62.92±42.92 50.68±39.57 0.866 0.655 Page turning NDH (time) 7.98±3.75 6.34±2.30 0.889 7.80±4.01 8.87±3.25 0.208 0.248 Picking up small common objects NDH (time) 13.22±6.09 10.62±4.15 0.779 16.24±10.08 16.73±10.19 0.327 0.6 Simulated feeding NDH (time) 32.70±32.66 17.75±8.50 0.779 26.79±19.09 26.34±19.87 0.779 0.793 Stacking checkers NDH (time) 10.68±10.88 6.76±5.78 0.674 13.90±17.87 22.91±35.00 0.208 0.294 Moving large light objects NDH (time) 8.15±5.03 5.78±2.05 0.08 6.98±3.38 8.89±5.71 0.036 0.345 Moving large heavy objects NDH (time) 6.84±2.67 5.39±1.13 0.779 7.06±2.20 7.64±2.32 0.327 0.4 Writing DH (time) 39.99±21.68 38.40±24.66 0.674 38.40±24.66 37.21±23.44 0.674 0.834 Page turning DH (time) 8.00±2.75 6.34±2.30 0.093 6.34±2.30 8.14±3.16 0.069 0.208 Picking up small common objects DH (time) 12.26±2.14 10.62±4.15 0.208 10.62±4.15 13.02±5.25 0.263 0.529 Simulated feeding DH (time) 16.39±4.84 17.75±8.50 0.484 17.75±8.50 19.09±7.33 1 0.529 Stacking checkers DH (time) 7.84±4.47 6.76±5.78 0.401 6.76±5.78 8.15±3.76 0.123 0.208 ∗‡ Moving large light objects DH (time) 6.12±1.66 5.78±2.05 0.012 5.78±2.05 6.45±1.87 0.017 0.294 Moving large heavy objects DH (time) 6.11±1.30 5.39±1.13 0.208 5.39±1.13 7.01±1.93 0.263 0.093 ∗ ‡ ,e difference between pretreatment and posttreatment in the control group is statistically significant. ,e difference between pretreatment and posttreatment in the experimental group is statistically significant. DH: dominant hand; NDH: nondominant hand. Time in seconds. Table 3: Differences pre-post intervention in Grooved Pegboard Test (GPT) in the control group and experimental group. OT OT+VR GPT p Pretreatment Posttreatment Pretreatment Posttreatment p p Mean±SD Mean±SD Mean±SD Mean±SD Time NDH 339.12±277.94 340.25±276.80 0.686 340.25±276.80 336.18±277.73 0.715 0.955 Number of fallen pegs 3.71±2.98 4.85±3.62 0.245 4.85±3.62 5.37±4.56 0.336 0.861 (and collected to replace) NDH Number of correctly placed pegs NDH 20.14±8.47 21.14±4.63 0.465 15.37±9.67 21.14±4.63 0.078 0.239 Time DH 203.52±83.98 185.40±58.03 0.499 185.40±58.03 205.58±74.64 0.237 0.674 Number of fallen pegs 3.37±3.20 2.50±1.92 0.246 2.50±1.92 3.25±3.41 0.226 0.915 (and collected to replace) NDH Number of correctly placed pegs NDH 23.75±3.53 24.00±2.82 0.317 24.00±2.82 22.75±4.30 0.18 0.538 DH: dominant hand; NDH: nondominant hand. Time in seconds. significance,possiblyduetothereducedsamplesizeafterthe limb movements, faster performance. and a greater efficiency lossesexperiencedduringthestudy.Itiswell-knownthatthe in the performance of certain functional tasks. Previous qualitative studies [21] on the subjective experience of using performanceoffunctionaltasks,repeatedovertimeandwith certainvariability,canleadtoarelearningofskills.,isisan VRsystems,basedonvideocaptureofmovementwithKinect aspect reinforced by VR by offering feedback of results in as a therapeutic tool in patients with MS, have identified real time [17, 19, 20]. improvementsinpatient’sself-efficacyformanagementofthe We found no differences between the application of OT illness, social support, expectations, and training offered, as and OT+VR on the manual dexterity of MS patients with a well improvements in the behavior and perception of the moderatelevelofimpairmentinthePPT,JTT,andGPTtests. person’s own identity, and a positive association between the However, clinical improvements were found after the physical activities performed with VR and the real environ- OT+VR intervention, with improved precision of the upper ment. ,ese results have been confirmed in similar studies 6 Journal of Healthcare Engineering [22,23]highlightingthepotentialusefulnessoftheselow-cost Conflicts of Interest systems as a complement to conventional approaches from ,e authors declare that they have no conflicts of interest. the perspective of MS patients. As previously mentioned, we were unable to find pre- vious scientific studies associating improvements in ma- Authors’ Contributions nipulative dexterity using OT treatment approaches combinedwithVRinpatientswithMS.Shinetal.[24]found CNWP, CGC, and LAT performed treatments; MIJT was clinical improvements in manipulative dexterity after a VR responsible for the methodology; ABF, RCC, and RMOG interventioninpeoplewithbraininjury,measuredusingthe wereinvolvedinwritingandoriginaldraftpreparation;RCC PPT and JTT. Significant differences were however not was involved in writing, editing, and reviewing of the found in the cited study among the group receiving con- manuscript. ventional OT, leading the authors to conclude that the combination of conventional OT with VR may improve Acknowledgments global upper limb movements. Our results contrast partially withthosebyShinetal.asanimprovementseemstoexistin ,e authors would like to thank the subjects who partici- our OT group, as well as the OT+VR group, although pated in this study, without whose co-operation it would significant differences were not found between both study have been impossible to complete the research. groups. ,is suggests that both approaches could be valid, and, fundamentally, complementary. Findings by our re- References search group [17, 19, 20], as well as those reported by other authors[25],haveshown improvements inposturalcontrol, [1] WHO, Multiple Sclerosis International Federation. Atlas: optimization of the processing of the sensory information, Multiple Sclerosis Resources in the World, World Health and integration of the systems necessary for maintaining Organization, Geneva, Switzerland, 2008. balanceandposturalcontrolinpeoplewithMSviatheuseof [2] W. I. McDonald, A. Compston, G. 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