Effectiveness of Serious Gaming During the Multidisciplinary Rehabilitation of Patients With Complex Chronic Pain or Fatigue: Natural Quasi-Experiment.

BACKGROUND: Current evidence for the effectiveness of specialist multidisciplinary programs for burdensome chronic pain and functional somatic syndromes drives the effort to improve approaches, strategies, and delivery modes. It remains unknown to what extent and in what respect serious gaming during the regular outpatient rehabilitation can contribute to health outcomes. OBJECTIVE: The objectives of our study were to determine the effect of additional serious gaming on (1) physical and emotional functioning in general; (2) particular outcome domains; and (3) patient global impressions of change, general health, and functioning and to determine (4) the dependency of serious gaming effects on adherence. METHODS: We conducted a naturalistic quasi-experiment using embedded qualitative methods. The intervention group patients received an additional guided (mindfulness-based) serious gaming intervention during weeks 9-12 of a 16-week rehabilitation program at 2 sites of a Dutch rehabilitation clinic. Simultaneously, 119 control group patients followed the same program without serious gaming at 2 similar sites of the same clinic. Data consisted of 10 semistructured patient interviews and routinely collected patient self-reported outcomes. First, multivariate linear mixed modeling was used to simultaneously estimate a group effect on the outcome change between weeks 8 and 16 in 4 primary outcomes: current pain intensity, fatigue, pain catastrophizing, and psychological distress. Second, similar univariate linear mixed models were used to estimate effects on particular (unstandardized) outcomes. Third, secondary outcomes (ie, global impression of change, general health, functioning, and treatment satisfaction) were compared between the groups using independent t tests. Finally, subgroups were established according to the levels of adherence using log data. Influences of observed confounding factors were considered throughout analyses. RESULTS: Of 329 eligible patients, 156 intervention group and 119 control group patients (N=275) with mostly chronic back pain and concomitant psychosocial problems participated in this study. Of all, 119 patients played ≥75% of the game. First, the standardized means across the 4 primary outcomes showed a significantly more favorable degree of change during the second part of the treatment for the intervention group than for the control group (beta=-0.119, SE=0.046, P=.009). Second, the intervention group showed a greater outcome change in depressive mood (b=-2.748, SE=1.072, P=.011) but not in "insufficiency" or concentration problems. Third, no significant group effects on secondary outcomes were found. Fourth, adherence was generally high and invariant. CONCLUSIONS: The findings of this study suggest a very small favorable average effect on relevant health outcomes of additional serious gaming during multidisciplinary rehabilitation. The indication that serious gaming could be a relatively time-efficient component warrants further research into if, when, how, and for which patients serious gaming could be cost-effective in treatment and why. TRIAL REGISTRATION: Netherlands Trial Registry NTR6020; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=6020 (Archived by WebCite at http://www.webcitation.org/71IIoTXkj).

Motion-based equilibrium reprocessing therapy a novel treatment method for chronic peripheral vestibulopathies: A pilot study.

Rehabilitation for vestibular disease is a safe method to partially alleviate symptoms of vertigo. It was hypothesized that principles of military aviation vestibular desensitization procedures that have a success rate of more than 80% can be extrapolated to chronic vestibular disease as well.The virtual reality motion base computer-assisted rehabilitation environment was used as treatment modality in 17 patients. They were exposed to sinusoidal vertical passive whole body motion in increasing intensity for a maximum of 12 sessions. The Dizziness Handicap Inventory (DHI) was used for assessment of the subjective complaints of vertigo.The median DHI scores of 50 points at baseline dropped to 22 points (P <.001) at follow-up. Post hoc analysis showed significant differences in outcome between measurements at baseline and at the end of the treatment, between baseline and follow-up, but not between end of treatment and follow-up.This pilot study concerning motion-based equilibrium reprocessing therapy (MERT) shows that it is a simple, quick, and well-tolerated treatment option to alleviate symptoms in patients with chronic peripheral vestibulopathies.

Serious gaming during multidisciplinary rehabilitation for patients with complex chronic pain or fatigue complaints: study protocol for a controlled trial and process evaluation.

INTRODUCTION: Many individuals suffer from chronic pain or functional somatic syndromes and face boundaries for diminishing functional limitations by means of biopsychosocial interventions. Serious gaming could complement multidisciplinary interventions through enjoyment and independent accessibility. A study protocol is presented for studying whether, how, for which patients and under what circumstances, serious gaming improves patient health outcomes during regular multidisciplinary rehabilitation. METHODS AND ANALYSIS: A mixed-methods design is described that prioritises a two-armed naturalistic quasi-experiment. An experimental group is composed of patients who follow serious gaming during an outpatient multidisciplinary programme at two sites of a Dutch rehabilitation centre. Control group patients follow the same programme without serious gaming in two similar sites. Multivariate mixed-modelling analysis is planned for assessing how much variance in 250 patient records of routinely monitored pain intensity, pain coping and cognition, fatigue and psychopathology outcomes is attributable to serious gaming. Embedded qualitative methods include unobtrusive collection and analyses of stakeholder focus group interviews, participant feedback and semistructured patient interviews. Process analyses are carried out by a systematic approach of mixing qualitative and quantitative methods at various stages of the research. ETHICS AND DISSEMINATION: The Ethics Committee of the Tilburg School of Social and Behavioural Sciences approved the research after reviewing the protocol for the protection of patients' interests in conformity to the letter and rationale of the applicable laws and research practice (EC 2016.25t). Findings will be presented in research articles and international scientific conferences. TRIAL REGISTRATION NUMBER: A prospective research protocol for the naturalistic quasi-experimental outcome evaluation was entered in the Dutch trial register (registration number: NTR6020; Pre-results).

Short-Term Results of a Rehabilitation Program for Service Members With Lower Leg Pain and the Evaluation of Patient Characteristics.

INTRODUCTION: Lower leg pain (LLP), including medial tibial stress syndrome (MTSS) and chronic exertional compartment syndrome (CECS), remains a major problem for the military. OBJECTIVE: Evaluation of patient characteristics and short-term results of the rehabilitation program for service members used in the Military Rehabilitation Centre Aardenburg. METHODS: This retrospective study includes 161 service members of the Netherlands Armed Forces. Service members were grouped into the following diagnostic categories: MTSS (n = 47), conservative treatment of CECS (n = 34), and rehabilitation after operative intervention of the CECS (CECSo; n = 80). RESULTS: The results showed a significant improvement in all groups regarding the Patient-Specific Functional Scale (PSFS). Only the CECSo group showed significant improvement on the Numeric Pain Rating Score (NPRS). None of the patient characteristics like gender, age, military service, duration of symptoms, and treatment setting were identified to correlate with outcome results. CONCLUSIONS: Short-term results of the rehabilitation program for service members with LLP are successful as obtained with the PSFS. Evaluation by the NPRS seems insufficient and researchers should consider using other outcome measurements. The CECSo group seems to benefit the most from the rehabilitation program. No patient characteristics could be identified to correlate with outcome results.

How to systematically assess serious games applied to health care.

The usefulness and effectiveness of specific serious games in the medical domain is often unclear. This is caused by a lack of supporting evidence on validity of individual games, as well as a lack of publicly available information. Moreover, insufficient understanding of design principles among the individuals and institutions that develop or apply a medical serious game compromises their use. This article provides the first consensus-based framework for the assessment of specific medical serious games. The framework provides 62 items in 5 main themes, aimed at assessing a serious game's rationale, functionality, validity, and data safety. This will allow caregivers and educators to make balanced choices when applying a serious game for healthcare purposes. Furthermore, the framework provides game manufacturers with standards for the development of new, valid serious games.

Stepping strategies used by post-stroke individuals to maintain margins of stability during walking.

BACKGROUND: People recovering from a stroke are less stable during walking compared to able-bodied controls. The purpose of this study was to examine whether and how post-stroke individuals adapt their steady-state gait pattern to maintain or increase their margins of stability during walking, and to examine how these strategies differ from strategies employed by able-bodied people. METHODS: Ten post-stroke individuals and 9 age-matched able-bodied individuals walked on the Computer Assisted Rehabilitation Environment. Medio-lateral translations of the walking surface were imposed to manipulate gait stability. To provoke gait adaptations, a gait adaptability task was used, in which subjects occasionally had to hit a virtual target with their knees. We measured medio-lateral and backward margins of stability, and the associated gait parameters walking speed, step length, step frequency, and step width. FINDINGS: Post-stroke participants showed similar medio-lateral margins of stability as able-bodied people in all conditions. This was accomplished by a larger step width and a relatively high step frequency. Post-stroke participants walked overall slower and decreased walking speed and step length even further in response to both manipulations compared to able-bodied participants, resulting in a tendency towards an overall smaller backward margins of stability, and a significantly smaller backward margin of stability during the gait adaptability task. INTERPRETATION: Post-stroke individuals have more difficulties regulating their walking speed, and the underlying parameters step frequency and step length, compared to able-bodied controls. These quantities are important in regulating the size of the backward margin of stability when walking in complex environments.

Walking in an unstable environment: strategies used by transtibial amputees to prevent falling during gait.

OBJECTIVE: To investigate which strategies transtibial amputees use to cope with challenges of gait stability and gait adaptability, and how these strategies differ from strategies used by able-bodied controls. DESIGN: Cross-sectional study. SETTING: An instrumented treadmill mounted onto a 6°-of-freedom motion platform in combination with a virtual environment. PARTICIPANTS: Transtibial amputees (n=10) and able-bodied controls (n=9). INTERVENTIONS: Mediolateral (ML) translations of the walking surface were imposed to manipulate gait stability. To provoke an adaptive gait pattern, a gait adaptability task was used in which subjects had to hit virtual targets with markers guided by their knees. MAIN OUTCOME MEASURES: Walking speed, step length, step frequency, step width, and selected measures of gait stability (short-term Lyapunov exponents and backward and ML margins of stability [MoS]). RESULTS: Amputees walked slower than able-bodied people, with a lower step frequency and wider steps. This resulted in a larger ML MoS but a smaller backward MoS for amputees. In response to the balance perturbation, both groups decreased step length and increased step frequency and step width. Walking speed did not change significantly in response to the perturbation. These adaptations induced an increase in ML and backward MoS. To perform the gait adaptability task, both groups decreased step length and increased step width, but did not change step frequency and walking speed. ML and backward MoS were maintained in both groups. CONCLUSIONS: Transtibial amputees have the capacity to use the same strategies to deal with challenges of gait stability and adaptability, to the same extent as able-bodied people.

The effect of military motion-assisted memory desensitization and reprocessing treatment on the symptoms of combat-related post traumatic stress disorder: first preliminary results.

UNLABELLED: Although the symptoms of Post-Traumatic Stress Disorder (PTSD) in the general and military population seem very similar, combat-related PTSD (cr-PTSD) is typically thought to be more severe due to the repeated and prolonged exposure of traumatic events. Therapeutic adherence is reported a problem in military populations compromising treatment efficacy. Therefore, a new potential supplementary treatment is specially designed for patients with cr-PTSD. This intervention is called Military Motion Memory Desensitization and Reprocessing (3MDR). The treatment incorporates key elements of successful treatments as Virtual Reality Exposure (VRE) and Eye Movement Desensitization Reprocessing (EMDR) and adds motion to the condition. We aimed at designing a treatment procedure that preserved dual task processing principle, yet introduced new engagement by performing the desensitization during motion by to walking on a treadmill. Moreover, we aimed at exposure to real high-affect pictures of deployment setting. Subjects walk a repetitive cycle while walking and viewing high affect pictures of deployment scenes. Dual task processing was maintained by an oscillating ball. Aspects of presence are adhered to, to maximize possible positive outcome. METHOD: Two veterans with chronic PTSD, received four weekly sessions of 3MDR therapy. The indicator of effectiveness was difference in CAPS (Clinical Administrated PTSD Scale)-score. The treatment was designed on the Computer Assisted Rehabilitation Environment (CAREN) facility. RESULTS: The 3MDR treatment did further decrease PTSD symptoms. Patients were highly satisfied about the treatment and had no attention to drop out. CONCLUSION: The results of the two cases suggest that the 3MDR treatment is a successful, more additional treatment that goes further into the patients affect where other treatment may stagnate. The presence was highly appreciated. Further research with more patients needs to be performed to obtain more reliable results.

A virtual rehabilitation program after amputation: a phenomenological exploration.

PURPOSE: This study provides an analysis of bodily experiences of a man with a lower leg amputation who used a virtual rehabilitation program. METHOD: The study reports data from semi-structured interviews with a 32-year veteran who used a virtual environment during rehabilitation. The interviews were analyzed using interpretative phenomenological analysis (IPA). RESULTS: During this rehabilitation program, he initially experienced his body as an object, which he had to handle carefully. As he went along with the training sessions, however, he was more stimulated to react directly without being aware of the body's position. In order to allow himself to react spontaneously, he needed to gain trust in the device. This was fostered by his narrative, in which he stressed how the device mechanically interacts with his movements. CONCLUSION: The use of a virtual environment facilitated the process of re-inserting one's body into the flow of one's experience in two opposite, but complementary ways: (1) it invited this person to move automatically without taking into account his body; (2) it invited him to take an instrumental or rational view on his body. Both processes fostered his trust in the device, and ultimately in his body. IMPLICATIONS FOR REHABILITATION: Providing (more) technological explanation of the technological device (i.e. the virtual environment), may facilitate a rehabilitation process. Providing (more) explicit technological feedback, during training sessions in a virtual environment, may facilitate a rehabilitation process.

Stepping strategies for regulating gait adaptability and stability.

Besides a stable gait pattern, gait in daily life requires the capability to adapt this pattern in response to environmental conditions. The purpose of this study was to elucidate the anticipatory strategies used by able-bodied people to attain an adaptive gait pattern, and how these strategies interact with strategies used to maintain gait stability. Ten healthy subjects walked in a Computer Assisted Rehabilitation ENvironment (CAREN). To provoke an adaptive gait pattern, subjects had to hit virtual targets, with markers guided by their knees, while walking on a self-paced treadmill. The effects of walking with and without this task on walking speed, step length, step frequency, step width and the margins of stability (MoS) were assessed. Furthermore, these trials were performed with and without additional continuous ML platform translations. When an adaptive gait pattern was required, subjects decreased step length (p<0.01), tended to increase step width (p=0.074), and decreased walking speed while maintaining similar step frequency compared to unconstrained walking. These adaptations resulted in the preservation of equal MoS between trials, despite the disturbing influence of the gait adaptability task. When the gait adaptability task was combined with the balance perturbation subjects further decreased step length, as evidenced by a significant interaction between both manipulations (p=0.012). In conclusion, able-bodied people reduce step length and increase step width during walking conditions requiring a high level of both stability and adaptability. Although an increase in step frequency has previously been found to enhance stability, a faster movement, which would coincide with a higher step frequency, hampers accuracy and may consequently limit gait adaptability.

Prevalence of modic changes in active duty military men with lumbar disk herniation who were scheduled for surgery.

OBJECTIVE: The purpose of this study was to report on the prevalence of Modic changes (MCs) in a group of Netherlands military men who were scheduled for surgery (lumbar discectomy). METHODS: This was a retrospective observational study of health records. From 133 patients in active military service seen from January 2004 to March, 77 case files were selected. For all subjects who met inclusion criteria, the health records and T1- and T2-weighted magnetic resonance imaging files of lumbar levels L4/L5 and L5-S1 were assessed. Data including age, sex, rank in military, level of lumbar herniation, and level of MC including their types were evaluated. RESULTS: Nineteen subjects (24.7%) showed presence of MC at the level of disk herniation, 5 subjects (6.5%) showed MC at a different level, and 10 subjects (13%) showed MC at both levels. In total, 154 segments were analyzed on magnetic resonance imaging for present MC of which 44 levels (28.6%) showed MC type I (31.8%), type II (65.9%), or type III (2.3%). Higher age showed to be significant (P ≤ .001) on developing MC, but no significance was found for physical workload in relation to these changes. CONCLUSIONS: For the subjects in this study, MCs were most common at the lower lumbar spine segments, with a predominance of type II. In this study, the presence of a disk herniation and MC at the same level was 37.7%; however, a significant association was not demonstrable.

[Dutch military casualties of the war in Afghanistan--quality of life and level of participation after rehabilitation]. / Nederlandse militaire oorlogsslachtoffers uit Afghanistan--kwaliteit van leven en participatieniveau na revalidatie.

OBJECTIVE: To describe the distribution of injuries and the quality of life and functioning at activity and participation level of rehabilitated Dutch military personnel who were wounded during the mission to Afghanistan. DESIGN: Retrospective, descriptive. METHOD: The study population consisted of military war casualties who followed multidisciplinary rehabilitation treatment for injuries sustained in combat in Afghanistan. Distribution and degree of injuries were classified according to the 'Abbreviated Injury Scale' (AIS) and the 'Injury Severity Score' (ISS). Quality of life and functional disabilities were assessed with a semi-structured interview, and the following questionnaires: EuroQol-5D with an extra dimension 'cognition' (EQ-6D), the 'Assessment of Life Habits' shortened version 3.0 (LIFE-H 3.0) and the 'Lower Extremity Functional Scale'(LEFS). Coping style was assessed with the Cognitive Emotion Regulation Questionnaire' (CERQ). RESULTS: A total of 48 servicemen cooperated. A total of 248 injuries; 54% of which affected the extremities. In 9 victims an amputation of the lower extremity was performed; 4 of them had to have a double amputation. 31 servicemen were still receiving specialist medical care at the time of the interview. 39 servicemen had to adjust their career plans. The mean quality of life, measured by EQ-5D, had an index score of 0.72 (Dutch population norm: 0.88). The mean score on the LEFS was 58 (maximum score 80). Changes in mobility and occupation appeared to be predictive factors for quality of life. CONCLUSION: The quality of life and functional level of Dutch military personnel who were injured in combat in Afghanistan seemed to be lower than in the general population after 2.3 years. For a large part this could be explained by the level of mobility and occupation.

Speeding up or slowing down?: Gait adaptations to preserve gait stability in response to balance perturbations.

It has frequently been proposed that lowering walking speed is a strategy to enhance gait stability and to decrease the probability of falling. However, previous studies have not been able to establish a clear relation between walking speed and gait stability. We investigated whether people do indeed lower walking speed when gait stability is challenged, and whether this reduces the probability of falling. Nine healthy subjects walked on the Computer Assisted Rehabilitation ENvironment (CAREN) system, while quasi-random medio-lateral translations of the walking surface were imposed at four different intensities. A self-paced treadmill setting allowed subjects to regulate their walking speed throughout the trials. Walking speed, step length, step frequency, step width, local dynamic stability (LDS), and margins of stability (MoS) were measured. Subjects did not change walking speed in response to the balance perturbations (p=0.118), but made shorter, faster, and wider steps (p<0.01) with increasing perturbation intensity. Subjects became locally less stable in response to the perturbations (p<0.01), but increased their MoS in medio-lateral (p<0.01) and backward (p<0.01) direction. In conclusion, not a lower walking speed, but a combination of decreased step length and increased step frequency and step width seems to be the strategy of choice to cope with medio-lateral balance perturbations, which increases MoS and thus decreases the risk of falling.

Impact of alignment to gravito-inertial force on motion sickness and cardiopulmonary variables.

INTRODUCTION: In tilting trains partial alignment to the gravito-inertial force (GIF) in the curves seems to be the best tilt compensation to reduce the incidence of motion sickness. We investigated the effect of alignment to the GIF on the development of motion sickness during low-frequency horizontal motion. METHODS: There were 12 healthy subjects who participated. The design was a three-period, single-blind, crossover trial, counterbalanced for order. Cardiopulmonary measurements, Misery SCores (MISC), and questionnaire data (Motion Sickness Susceptibility Questionnaire, Nijmegen Questionnaire for Hyperventilation) were obtained. The stimulus was a sinusoidal movement (0.176 Hz, 0.2 g peak acceleration) on the ESA-sled. The cabin was compensated for 0% (A-0), 50% (A-50), and 100% (A-100) to the GIF. Runs were 1 wk apart. RESULTS: The A-50 condition may delay the development of motion sickness. Based on the survival curves the possible effect seems temporary. However, MISC 2 early in the runs resulted in high positive and negative predictive values for dropout and survival during the runs. No synchronization of the respiratory frequency with the sled motion was observed. There was a significant (P = 0.002) drop in relative end-tidal CO2 levels. DISCUSSION: There seems to be a rationale for partially compensating to the GIF while trying to prevent motion sickness in tilting trains. Sitting comfort is just better than without compensation at all and Coriolis effects are not as nauseating as with complete tilt compensation. Also, a drop in end-tidal CO2 levels might be a sign of pulmonary compensation for the nauseating stimulus.

Respiratory impact on motion sickness induced by linear motion.

Motion sickness incidence (MSI) for vertical sinusoidal motion reaches a maximum at 0.167 Hz. Normal breathing frequency is close to this frequency. There is some evidence for synchronization of breathing with this stimulus frequency. If this enforced breathing takes place over a larger frequency range (0.05-0.8 Hz) and whether this contributes to the high MSI at 0.167 Hz was investigated. Sinusoidal motion (amplitude 0.3 g, frequencies 0.05, 0.1, 0.2, 0.4, and 0.8 Hz) was applied. Nausea with the MISC-scores and respiratory parameters, such as tidal volume, respiratory frequency, end-tidal CO(2) (PetCO(2)), and respiratory minute volume, were measured. Control conditions included rest and the hyperventilation provocation test. The nausea scores were highest at 0.2 Hz. With increasing frequencies the respiratory minute volume increased and the PetCO(2) values decreased. The hyperventilation provocation test did not cause nausea. The main conclusion is that the high MSI at 0.167 Hz is not due to enforced breathing, since enforced breathing still increases with higher stimulus frequencies.

Hyperventilation in a motion sickness desensitization program.

INTRODUCTION: In motion sickness desensitization programs, the motion sickness provocative stimulus is often a forward bending of the trunk on a rotating chair, inducing Coriolis effects. Since respiratory relaxation techniques are applied successfully in these courses, we investigated whether these repetitive trunk movements by themselves may induce hyperventilation and consequently add to the motion sickness. METHODS: There were 12 healthy subjects who participated in our study. In the Baseline condition, subjects sat relaxed on the stationary chair. In the Hypervent condition, subjects performed voluntary hyperventilation (the level was prescribed). In two other conditions subjects rhythmically bent their trunk on a stationary chair (Tilt-Stat condition) and on a rotating chair (Tilt-Rot condition). In all conditions we measured respiratory and cardiovascular activity (heart frequency, tidal volume, end-tidal CO2, and respiration frequency). RESULTS: Of the 12 subjects, 9 had to stop prematurely in the Tilt-Rot condition because of moderate nausea. Except for heart rate in the Tilt-Rot condition, the measured physiological parameters in these subjects in the Tilt-Stat and Tilt-Rot conditions were not statistically different from the Baseline condition. Only in the Hypervent condition were significant differences observed, but no nausea. DISCUSSION: The findings show that hyperventilation is not the main cause of nausea during the Coriolis effects. We conclude that during the pilot desensitization program with Coriolis stimuli, measurement of cardiovascular and respiratory parameters is not necessary; however, in those cases that do not respond to the intervention, we recommend paying attention to respiratory parameters because hyperventilation does occur on an individual basis.