Serious Games-based System to Train Weight Shifting and Balance

after Stroke at Home

Description of a Pilot Study and Preliminary Experience

M. Pajaro-Blázquez, A. Dueñas-Ruiz, B. Ferrer-Gonzalez, A. Moreno-Conde, F. Jódar-Sánchez

and C. Parra

Technological Innovation Group, Virgen del Rocío University Hospital, Manuel Siurot Avenue, s/n, 41013 Seville, Spain

Keywords: Serious Games, Telerehabilitation, Stroke.

Abstract: Serious games specifically designed for rehabilitation have the potential to improve motor deficits and can

be used to enhance functional recovery after stroke. Serious games provide a repetitive and structured game-

based training while monitoring user performance and progress. In this paper, we present a description of an

ongoing pilot study of a serious games-based system to train posture, balance and weight shifting after

stroke at home. We also present a preliminary description of three patients enrolled in the pilot study that

are successfully accomplishing an in-home training program showing good adherence, acceptance and

satisfaction with the technology.

1 INTRODUCTION

Overall, in year 2010, an estimated 16.9 million

cases of incident stroke took place worldwide, 33

million prevalent stroke cases, 5.9 million stroke

deaths, and 102.2 million disability-adjusted life

years lost (Feigin et al., 2014). Stroke affects

physical, cognitive and emotional functioning, but

there are interventions that can be done to reduce the

impact of post-stroke effects. Despite adequate

treatment, stroke survivors experience a broad range

of lasting deficits that can impact their cognitive,

visual and motor systems. Moreover, at six to twelve

months after stroke, only 60% of the patients are

independent in personal care, 30% to 40% present

depression and 50% need help either with shopping

or housework (Cheeran et al., 2009). Given the

increasing figures of such events, this poses a large

burden to the National Health Service Providers that

have become overly saturated and are forced to

shorten the duration of the rehabilitation service.

Stroke has an enormous socioeconomic impact also

on the patient’s families that often feel left alone by

the health service providers. Patients that should

continue the therapy outside the hospital actually

drop out mostly due to high costs (Langhorne &

Duncan, 2001).

New technology presents potential benefits for

therapy and can represent an effective way of

providing intensive and structured rehabilitation at a

distance (telerehabilitation) to people with lasting

motor impairments after stroke (Loconsole, Bannò,

Frisoli, & Bergamasco, 2012). The field of game-

based rehabilitation for stroke is growing into a

significant area spurred by the growth in the use of

video games and of new methods for their

development (Fernández-Baena, Susín, & Lligadas,

2012). There are a number of studies published

related to the use commercial games for stroke

rehabilitation (Crosbie, McNeill, Burke, &

McDonough, 2009; Hung et al., 2014; Pedro & De

Paula Caurin, 2012), but efforts in the field of

customizing and creating specific games for

rehabilitation are increasing because commercial

games does not fit properly to the demands and

characteristics of these patients (Sandlund,

McDonough, & Häger-Ross, 2009). Serious Games

are aimed at improving motor deficits while

monitoring and evaluating patient progress, and

offer game-based rehabilitation environments that

motivate the patient during training (Webster &

Celik, 2014). The virtual environment of serious

games can provide safe and customizable training,

which may be tailored to a patient’s interest and

physical abilities. Serious games technology allows

135

Pajaro-Blázquez M., Dueñas-Ruiz A., Ferrer-Gonzalez B., Moreno-Conde A., Jódar-Sánchez F. and Parra C..

Serious Games-based System to Train Weight Shifting and Balance after Stroke at Home - Description of a Pilot Study and Preliminary Experience.

DOI: 10.5220/0005190401350142

In Proceedings of the 2nd International Congress on Neurotechnology, Electronics and Informatics (VirtRehab-2014), pages 135-142

ISBN: 978-989-758-056-7

 2014 SCITEPRESS (Science and Technology Publications, Lda.)

monitoring user performance to analyze results over

time (Deutsch et al., 2012). In this field, previous

studies reported the effectiveness of balance training

performed with video game-based therapy with Wii

Fit for improving balance and for reducing disability

in patients in the subacute phase after stroke

(Morone et al., 2014).

The potential of serious games to help deliver

rehabilitation at home still needs to be explored as a

tool to provide telerehabilitation. Although the

telerehabilitation is a viable alternative way of

delivering rehabilitation services, a systematic

review of telerehabilitation services for stroke

concluded that the evidence was insufficient to draw

conclusions on the effects of the intervention on

mobility, health-related quality of life or participant

satisfaction with the intervention. Moreover, no

studies evaluated the cost-effectiveness of

telerehabilitation (Laver et al., 2013).

We hypothesize that using an in-home virtual

reality system that aims to train posture and balance

at home is feasible and that the regularly training

with the system may improve balance, endurance

and motor function after stroke. The goal of this

paper is to describe the ongoing pilot study to

evaluate the use of a serious games-based

rehabilitation system constituted by a multi-level

rehabilitation platform and to give a preliminary

description of the experience of three patients with

post-stroke hemiparesis enrolled in the study that are

using the system at home.

2 MATERIAL AND METHOD

2.1 Recruitment and Study Population

Patients are recruited from the rehabilitation

department of the Virgen del Rocío University

Hospital (Seville, Spain). Patients meeting the

inclusion criteria are fully informed and included in

the study after signing the informed consent form.

The inclusion criteria are as follows: age over 18

years old, history of stroke ≥ 3 months, signed

informed consent, presence of caregivers,

Minimental State Examination score > 20, training 2

weeks at the hospital, Functional Ambulation

Classification > 3, ability to walk for six minutes,

Berg Balance Scale > 21, enough working space at

home for the use of the REWIRE system and WiFi

connection. The exclusion criteria are as follows:

previous neurological progresive disease, pain that

impossibility the use of the platform, psychiatric

illness, emotional deficit, vision impairments. The

pilot study received the aproval of the Ethical

Committe of our institution prior patient enrollment

2.2 Multilevel Platform

The REWIRE project develops and tests an

innovative rehabilitation platform based on a virtual

reality , which allows patients, discharged from the

hospital, to continue intensive rehabilitation at home

under remote monitoring by the hospital itself. The

main idea is to assemble off the shelf components in

a robust and reliable way to get a multilevel platform

system that enable to be deployed massively at the

patients’ homes. The platform is constituted of three

hierarchical components: a patient station (PS),

deployed installed at home, a hospital station (HS)

and a networking station (NS) at the health provider

site.

The PS is based on video-based tracking

(through a mix of 2D and 3D cameras) and virtual

reality. The patients perform their training or “

serious games” at home through a Kinect and force

platform systems (Tymo plate by Tyromotion, Graz,

Austria). The patient sees himself/herself or an

avatar interacting in real time with a virtual game.

Game variety of scenarios, balanced scoring system,

quantitative exercise evaluation, audio-visual

feedback aims at maximum patient’s motivation. A

robust and reliable auto-calibration and spatial

synchronization with the graphics is developed.

Patient’s daily activity is monitored by a Body

Sensor Networks (Lifestyle system) and his activity

is profiled through eigenbehavior (Krause, Lusseau,

& James, 2009). Environmental, physiological and

motion data are combined to tune the rehabilitation

exercise level, to assess potential risks and advice

clinicians on the therapy.

The HS main role is the definition and

monitoring of the treatment. Data mining in the NS

discovers common features and trends of

rehabilitation treatment among hospitals and

regions. A virtual community is setup to educate and

motivate patients (Wüest et al., 2014).

2.2.1 Serious Games

A set of ten serious games is available for the

intervention. Each game offers different difficulty

levels, ranging from 1 (lowest degree of difficulty)

to 5 (highest degree of difficulty).

1. “Balloon popper”: the goal of the game is to pop

the balloons that appear on the screen. To pop the

balloons, the patient should move the hips in all

directions (shifting the weight) to reach the balloons.

NEUROTECHNIX2014-InternationalCongressonNeurotechnology,ElectronicsandInformatics

136

To score points, the patient should pop red balloons.

If the patient pops blue balloons instead, an “X” icon

appears on the screen showing that he/she made an

error. A big blue hand represents the patient’s

movements as an avatar.

2. “Bubbles”: The objective of this game is to pop

the bubbles that appear inside a cauldron. The

patient is represented as a wooden stick. The hips

are used to pop the bubbles (Figure 1).

3. “Fire fighter”: In this game a 3D avatar man

inside a barn will represent the patient. To score

points, the patient should step over a fire that

appears around him/her (in eight different

directions). To extinguish the fire, the patient needs

to stay a determined amount of time over the flame.

If the patient does not extinguish it, the hay bales

that are in the barn may burn and the patient will

lose points.

C D

Figure 1: Videogames screenshots: A. Bubbles; B: animal

hurdler; C. Fruit catcher; D. Horse runner.

4. “Animal hurdler”: The purpose of this game is to

raise the leg when some small worms approach to

the 3D avatar man. Depending on the side of the

worm approaches, the patient will need to raise the

right or the left foot (Figure 1).

5. “Fruit catcher”: The objective of the game is

to catch apples falling from the top of the tree. In

“Fruit catcher” the patient will be represented as a

3D avatar man represented in front of a tree with a

basket on the head. To catch the fruit, the patient

should shift the body weight or step to the sides. The

patient will score points when the fruits fall into the

basket placed over the avatar´s head (Figure 1).

6. “Hay collect”: The objective of this game is to

shift the body weight to the left or to the right, and

score points collecting the hay bales scattered

around the field. In this game the patient´s avatar is

driving a tractor travelling forward automatically.

The score decreases when the patient does not

collect the bales or if the avatar hits against rock

formations.

7. “Scare crow”: The objective of this game is that

the patient increases his balance and equilibrium. In

this game, a scarecrow placed in a crop field

represents the patient. Birds come from the sky to

alight upon you. If the patient moves when the birds

are approaching to the avatar, the birds will be

scared and the patient looses points.

8. “Pump the wheel”: In this game the patient should

raise both legs alternately, as previously described in

“Animal hurdler”. The patient is represented by a 3D

avatar man that operates a pump connected to an

empty flat of a tractor that is in front of the avatar.

Patient operates the pump rising and lowering the

legs at both sides alternatively. A blue arrow

indicates which leg the patient has to lift and the

height necessary to achieve points.

9. “Horse runner”: The patient has to stand up to run

faster and getting floating honey jars (it give you

points) and to sit down to run slower and avoiding

branches (Figure 1). An avatar of a man who is on

the top of a horse represents the patient. The horse is

running in the woods and advances automatically.

10. “Butterfly catcher:” The objective of this game is

to catch butterflies appearing from one side of the

screen to the other. A floating butterfly net

represents the patient, who has to use the body

movements to catch butterflies (moving the hips). If

the patient catches dragonflies instead of butterflies,

he/she looses points.

2.3 Intervention

Description of the recruitment and intervention

protocol of the pilot study is presented in Figure 2.

2.3.1 Two-Week Training at the Hospital

Patients complete a two-week training program at

the hospital to instruct patients and caregivers in the

use the REWIRE platform (Figure 3). Caregivers are

encouraged to observe hospital training sessions. It

is required that one or more caregivers attend at least

one session in order to learn to assist in the system

SeriousGames-basedSystemtoTrainWeightShiftingandBalanceafterStrokeatHome-DescriptionofaPilotStudyand

PreliminaryExperience

137

Figure 2: Pilot study flowchart.

Figure 3: Patient 1 performing a session during the two-

week hospital training.

utilization. At the end of the hospital training,

patients are able to set up the equipment correctly

and to complete a programmed session through the

PS. Patients are also instructed to solve simple issues

that may arise during sessions without assistance.

Assistance from caregivers is allowed to solve

potential issues if necessary.

Through the hospital training subjects are also

instructed in the use of the Lifestyle system.

During these two-week training, a physical

therapist defines subject’s motor and function ability

in order to program and customize sessions to

patient clinical characteristics.

At the end of these two weeks of training,

patients complete the usability questionnaire

Technology Acceptance Model (TAM). The TAM

questionnaire comprises 24 items (divided into four

sections detailed, Table 3) that are scored using a 7-

point Linkert scale ranging from “strongly disagree”

(scored as 1) to “strongly agree” (scored as 7). This

questionnaire explains the perceived usefulness and

usage intentions about a technology (Davis,

Bagozzi, & Warshaw, 1989; Davis, 1989;

Venkatesh, Davis, & College, 2000).

2.3.2 Three-Month Training at Home

After completing the two-week hospital training, the

REWIRE system is installed at patient's home to

start three-month intervention training. Three to five

sessions per week for a period of twelve weeks

(ranging from 36 to 60 session) are programmed for

every patient. The clinical team involved in the

investigation decides the number of sessions per

week for each patient, according to clinical criteria.

The length of each session time is 20 to 25 minutes

of actual training (time spent playing games). In

addition, subjects are allowed to rest as much as they

need between games.

2.3.3 Communication Between the Patient

and Clinicians

The PS includes a tool that allows for

communication between participants and clinicians

involved in the investigation through the HS. This

tool allows to participate in a forum for patients and

clinicians, to send direct messages to the therapist

and to make a video calls. Direct phone calls are

allowed in case of incidences during the session that

interfere with the training performance. The number

of phone calls made and time required for the

assistance are recorded to evaluate the usability and

costs at the end of the study.

2.3.4 Displacement to the Patient’s Home

The therapist is expected to go to the patient's home

in eight different scheduled visits (V):

- V1: the first day at the beginning of the in-home

training program to install the REWIRE system.

- V2-V7: to provide the Lifestyle system at the

beginning of the monitoring period, and to

collect the systems when done.

NEUROTECHNIX2014-InternationalCongressonNeurotechnology,ElectronicsandInformatics

138

- V8: to collect the REWIRE system at the end of

the three-months training period.

Additional visits may be necessary in case of

technical problems that cannot be solved through the

PS or phone call. Number of additional visits to

patient’s home required and time expended during

the visits is registered.

2.3.5 Outcome Measures

Clinical outcome measures are listed in table 1.

The Lifestyle System is a sensor-based wearable

system used to evaluate movement during activities

of daily living (ADLs). The system is composed of 5

IMUs (Inertial Measure Unites) that allow

evaluating movements to assess changes in the

ADLs. The objective is ubiquitous lifestyle

evaluation using ambulatory monitoring under real-

life conditions, in order to provide a multi-

parametric overview of motor functions (upper limb,

gait, and posture) and physical activity in the

patient’s daily environment. The sensors have to be

worn in the morning and carried continuously during

the day. At the end of the day they can be taken out

and attached to the Lifestyle Station through

dedicated mini-USB connector. Three assessments

with the lifestyle system will be carry out: the first

week, the seventh and the last week. During every

evaluation, subjects wear the sensors for 5 days a

week, 8 consecutive hours per day.

Two clinicians with experience in clinical

assessments measurements performed the evaluation

three times:

- T 0- before intervention: clinical assessments

and activity monitoring with the lifestyle system.

- T 1- one month after the beginning of the

intervention: clinical assessments and activity

monitoring with the lifestyle system (seventh week).

- T 3- at the end of the 3-months intervention:

clinical assessments and activity monitoring with

lifestyle system.

3 PRELIMINARY RESULTS

Fifteen eligible candidates were identified to

participate and completed the screening evaluation.

Nine out of fifteen patients were not enrolled (one

patient due to marked proprioception impairments,

one patient due to severe aphasia, two patients did

not have enough available space at home to use the

platform, two refused to participate, one did not

Table 1. List of clinical outcome measures evaluated in

this pilot study. Abbreviations: NIHSS, National Institute

of Health Stroke Scale; MMSE, Minimental State

Examination; ZüMAX, Zurich Maximental Status.

DOMAIN MEASUREMENT

INSTRUMENTS

Stroke deficit

severity

Fugl Meyer (lower limb)

IHSS

Motor Function

Berg Balance Scale (primary

outcome measure)

Six Minutes Walking Test

Ashworth

Cognitive deficit

MMSE

ZüMAX

Functional level

Barthel Index

Modified Rankin Scale

Timed Up and Go

Quality of Life

EuroQol Quality of Life Scale

(EQ5D)

Stroke Impact Scale -16 (SIS-16)

Questionnaires

TAM (Technology Acceptance

Model)

Patient Doctor Relationship

have internet connection at home, and two because

of absence of caregiver). Six patients signed the

informed consent, agreed to participate and were

enrolled in the study. After signing the informed

consent, one patient dropped out because the

primary caregiver was admitted to the hospital with

a serious illness. Three patients are performing the

in-home training phase (age, gender and diagnosis

described in Table 2) on the date of this article

submission. Baseline outcome measures of the three

patients are described in Table 3. The other two

patients already completed the two-week hospital

training.

An average of 6.16 phone calls per week made

by the patients were registered to date.

Phone calls made by patients were due to main

three reasons (ordered by frequency):

- Technical problems related to the games

during the session.

- To ask questions about the installation of the

system components

- To inform a short period missing sessions due

to vacation, illness or other personal

reasons.

SeriousGames-basedSystemtoTrainWeightShiftingandBalanceafterStrokeatHome-DescriptionofaPilotStudyand

PreliminaryExperience

139

Table 2. Clinical characteristics of three patients included

in the pilot study. Abbreviations: MMSE, Minimental

State Examination; FAC, Functional Ambulation

Category.

Patient 1 Patient 2 Patient 3

Age

32 72 65

Gender

Female Female Male

Diagnosis

Left hemispheric

Ischemic Stroke

Left hemispheric

Ischemic Stroke

Right hemispheric

Ischemic Stroke

Months since

stroke

3 8 7,5

MMSE

35 25 32

FAC

5 3 3

Table 3. Baseline outcome measures and description of the

training of three patients included in the pilot study.

Abbreviations: 6MWT, Six Minutes Walking Test; m,

meters; BBS, Berg Balance Scale; TAM, Technology

Acceptance Model; SD: Standard deviation.

Patient 1 Patient 2 Patient 3

BBS

55 42 38

6MWT (m) 414 136 171

TAM

Questionnaire

- Perceived Ease

of Use

6 6.3 6.9

- Perceived

Usefulness

6.2 6.5 6.7

- Attitude

Toward Using

7 5 7

- Behavioral

Intention to Use

5.5 4.5 7

6 weeks-

training

- Sessions per

week

3.5 (3-5)

4.66 3.33

- Session

duration

(minutes)

(means ± SD)

37.01 ±

13.65

30.86 ± 8.07 29.72 ± 6.17

The phone calls made by the staff involved in the

study to contact patients were needed due to the

following reasons (ordered by frequency):

- Resolution of technical problems related the

system functioning.

- To schedule programmed therapist visits.

- To schedule visits to make the assessments.

A total of 16 visits to the patients home were

required during the first 6-weeks training, included

expected scheduled visits and additional visits,

involving an overall time of 23.75 hours (including

time for displacement and time spent at patients

home), with an average of 3.80 ± 5.29 hours per

week.

4 DISCUSSION

This paper describes the pilot study protocol and the

requirements to support and monitor the use of a

serious game-based system to train patients after

stroke at home. Three patients enrolled to date are

successfully training at home with the system,

showing good adherence to treatment and

motivation, as shown by the successful completion

of the programmed sessions. Satisfaction and good

acceptance from users is reflected by the positive

results obtained in the TAM questionnaire at the

beginning of the intervention. Phone assistance was

often required at the first stage of the in-home

training phase, but was progressively decreasing due

system modifications and adaptation successfully

implemented and to increase experience of the

patients in the use of the system.

This study goes a step beyond others studies

reported with the system because we described the

successfully transference of the training to the

patients home. Wüest et. al. (Wüest et al., 2014)

described the results of 13 elderly participants that

completed thirty-six sessions of twenty minutes with

five exergames of the REWIRE project for twelve

weeks. They found a significant improvement with

moderate to large effect sizes in Berg Balance Scale

(P = 0.007, r = 0.51) in the 7-m Timed Up and Go (P

= 0.002, r = 0.56) after training, and in the Short

Physical Performance Battery (P = 0.013, r = 0.48).

Wüest et al. described that subjects evaluated

positively the usability of the virtual reality training

intervention, assessed by the TAM questionnaire. In

contrast with Wüest et al. study protocol, which

involved the presence of an instructor during the

sessions, in our pilot study subjects complete the

sessions independently at home through the virtual

platform that allows monitoring the results at the

hospital through the HS. In the protocol of this pilot

study, individualized sessions are programmed from

the HS and are progressively adapted to subject

progresses and adherence. In addition, subjects

enrolled in our study present post-stroke residual

hemiparesis, increasing the challenge of the use of

virtual games at home.

The main challenges faced at the beginning of

the study were: frequency of system fails due to a

number of reasons related to the performance and

completion of the scheduled sessions, interaction

between the patient and objects captured by the

kinect at home and kinect calibration malfunctions.

All issues were successfully solved after some fine-

tuning adjustments and some modifications made by

the engineers and therapist participating in the study,

NEUROTECHNIX2014-InternationalCongressonNeurotechnology,ElectronicsandInformatics

140

increasing the system robustness and allowing to

perform the home program.

Study staff dedicated a significant amount of

time to attend phone calls and solve issues after

installing the system at home, especially during the

first two weeks. Although for the first weeks the

phone was the more efficient communication tool, it

is expected that all the consultations and issues will

be solved through the communication tool of the

REWIRE platform during the following weeks.

Similarly, the time spent on subjects-home visits

was variably distributed among weeks, including

some weeks where no visit was required and others

weeks that required significant in-person assistance

at patients home.

Although ideally, all stroke rehabilitation

exercises should be performed with therapist-

assisted daily practice; it is not feasible in most of

the health care systems due to the high cost of the

demand of therapists (Webster & Celik, 2014). The

final results of this study will analyze the cost

associated with the intervention and its benefit in

terms of clinical improvement and quality of life

related to health compared to conventional

rehabilitation in the hospital.

5 CONCLUSIONS

A multilevel rehabilitation platform to train balance

deficits at home has been successfully installed at

patients home. Preliminary experience shows good

adherence, satisfaction and good acceptance from

users, although close contact and feedback with the

hospital is still needed to solve initial issues. Further

studies with larger samples are needed to

demonstrate the benefits of these virtual systems for

stroke rehabilitation.

ACKNOWLEDGEMENTS

This work was partially supported by the REWIRE

project (www.rewire-project.eu), funded by the

European Commission under the FP7 framework

with contract 287713.

Author Disclosure Statement

No competing financial interests exist.

REFERENCES

Cheeran, B., Cohen, L., Dobkin, B., Ford, G., Greenwood,

R., Howard, D., … Wolf, S. (2009). The future of

restorative neurosciences in stroke: driving the

translational research pipeline from basic science to

rehabilitation of people after stroke.

Neurorehabilitation and Neural Repair.

doi:10.1177/1545968308326636

Crosbie, J. H., McNeill, M. D. J., Burke, J., &

McDonough, S. (2009). Utilising technology for

rehabilitation of the upper limb following stroke: the

Ulster experience. Physical Therapy Reviews.

doi:10.1179/108331909X12540993897892

Davis, F. D. (1989). Perceived Usefulness, Perceived Ease

of Use, and User Acceptance of Information

Technology. MIS Quarterly, 13, 319–340.

doi:10.2307/249008

Davis, F. D., Bagozzi, R. P., & Warshaw, P. R. (1989).

User acceptance of computer technology: A

comparison of two theoretical models. Management

Science, 35, 982–1003. doi:10.1287/mnsc.35.8.982

Deutsch, J. E., Brettler, A., Smith, C., Welsh, J., John, R.,

Guarrera-Bowlby, P., & Kafri, M. (2012). Nintendo

Wii Sports and Wii Fit Game Analysis, Validation,

and Application to Stroke Rehabilitation. Topics in

Stroke Rehabilitation. doi:10.1310/tsr1806-701

Feigin, V. L., Forouzanfar, M. H., Krishnamurthi, R.,

Mensah, G. A., Connor, M., Bennett, D. A., …

Naghavi, M. (2014). Global and regional burden of

stroke during 1990-2010: Findings from the Global

Burden of Disease Study 2010. The Lancet, 383, 245–

255. doi:10.1016/S0140-6736(13)61953-4

Fernández-Baena, A., Susín, A., & Lligadas, X. (2012).

Biomechanical validation of upper-body and lower-

body joint movements of kinect motion capture data

for rehabilitation treatments. In Proceedings of the

2012 4th International Conference on Intelligent

Networking and Collaborative Systems, INCoS 2012

(pp. 656–661). doi:10.1109/iNCoS.2012.66

Hung, J.-W., Chou, C.-X., Hsieh, Y.-W., Wu, W.-C., Yu,

M.-Y., Chen, P.-C., … Ding, S.-E. (2014). A

Randomized Comparison Trial of Balance Training by

Using Exergaming and Conventional Weight-Shifting

Therapy in Patients with Chronic Stroke. Archives of

Physical Medicine and Rehabilitation.

doi:10.1016/j.apmr.2014.04.029

Krause, J., Lusseau, D., & James, R. (2009). Animal social

networks: an introduction. Behavioral Ecology and

Sociobiology, 63(7), 967–973. doi:10.1007/s00265-

009-0747-0

Langhorne, P., & Duncan, P. (2001). Does the

organization of postacute stroke care really matter?

Stroke; a Journal of Cerebral Circulation, 32, 268–

274. doi:10.1161/01.STR.32.1.268

Laver, K. E., Schoene, D., Crotty, M., George, S., Lannin,

N. A., Sherrington, C., … Na, L. (2013).

Telerehabilitation services for stroke. The Cochrane

Database of Systematic Reviews, 12, CD010255.

doi:10.1002/14651858.CD010255.pub2

Loconsole, C., Bannò, F., Frisoli, A., & Bergamasco, M.

(2012). A new Kinect-based guidance mode for upper

SeriousGames-basedSystemtoTrainWeightShiftingandBalanceafterStrokeatHome-DescriptionofaPilotStudyand

PreliminaryExperience

141

limb robot-aided neurorehabilitation. In IEEE

International Conference on Intelligent Robots and

Systems (pp. 1037–1042).

doi:10.1109/IROS.2012.6386097

Morone, G., Tramontano, M., Iosa, M., Shofany, J.,

Iemma, A., Musicco, M., … Caltagirone, C. (2014).

The efficacy of balance training with video game-

based therapy in subacute stroke patients: A

randomized controlled trial. BioMed Research

International, 2014. doi:10.1155/2014/580861

Pedro, L. M., & De Paula Caurin, G. A. (2012). Kinect

evaluation for human body movement analysis. In

2012 4th IEEE RAS EMBS International Conference

on Biomedical Robotics and Biomechatronics BioRob

(pp. 1856–1861)doi:10.1109/BioRob.2012.6290751

Sandlund, M., McDonough, S., & Häger-Ross, C. (2009).

Interactive computer play in rehabilitation of children

with sensorimotor disorders: A systematic review.

Developmental Medicine and Child Neurology.

doi:10.1111/j.1469-8749.2008.03184.x

Venkatesh, V., Davis, F. D., & College, S. M. W. (2000).

Theoretical Acceptance Extension Model : Field Four

Studies of the Technology Longitudinal. Management

Science, 46, 186–204.

Webster, D., & Celik, O. (2014). Systematic review of

Kinect applications in elderly care and stroke

rehabilitation. Journal of Neuroengineering and

Rehabilitation, 11, 108. doi:10.1186/1743-0003-11-

108

Wüest, S., Borghese, N. A., Pirovano, M., Mainetti, R.,

van de Langenberg, R., & de Bruin, E. D. (2014).

Usability and Effects of an Exergame-Based Balance

Training Program. Games for Health Journal, 3, 106–

114. doi:10.1089/g4h.2013.0093

NEUROTECHNIX2014-InternationalCongressonNeurotechnology,ElectronicsandInformatics

142