Bilateral movement computer games improve upper limb recovery in stroke survivors

A randomized controlled trial conducted by researchers from Hong Kong Metropolitan University, the Hong Kong Polytechnic University and the Chinese University of Hong Kong found greater improvements in upper limb sensorimotor functions among subacute stroke survivors who engaged in bilateral movement-based computer games (BMCG) vs conventional rehabilitation (CR) alone.

Upper limb sensorimotor impairment affects up to two-thirds of stroke survivors, often leading to functional dependence and deteriorated quality of life. [J Neurol Phys Ther 2016;40:186-195; Stroke 2013;44:1111-1116] Virtual reality-based therapy allows performance of functional tasks in response to computer-generated stimuli that closely simulate reality, while keeping patients motivated, and its efficacy has been demonstrated in various neuroplasticity studies and clinical trials [Cochrane Database Syst Rev 2017;11:CD008349]

It has also been found that bilateral upper limb training is superior to unilateral training in improving upper limb motor impairment in stroke survivors. [PloS One 2019;14:e0216357] Therefore, present study hypothesized that use of customized BMCG could better engage people with stroke to practice functional training of both the paretic and non-paretic upper limbs simultaneously, and in turn, lead to better recovery of the paretic upper limb. [J Rehabil Med 2022;54:jrm00307]

Study participants (age, 45–85 years) were randomized to 16 sessions of CR plus BMCG (n=47) or CR plus video-directed exercise (VDE; n=46). In each session, the subjects in both study groups received 3 hours of CR consisting of physiotherapy and occupational therapy followed by 30 min of their assigned intervention (ie, BMCG or VDE).

During BMCG sessions, the subjects played three different computer games (10 min each) using a customized game controller. “They were required to move their paretic and non-paretic arms bilaterally in a nearly symmetrical and self-assistive pattern to complete the computer games, which required directional control, strategy, timing, strength, and endurance,” noted the researchers. During VDE, the subjects were instructed to perform conventional upper limb exercises that they had previously learned from attending training sessions at the geriatric day hospital.

Patients in the CR plus BMCG group demonstrated greater improvements in the primary outcome of upper limb impairment. After 8 weeks of treatment and 1-month follow-up, the mean Fugl-Meyer Assessment of the Upper Extremity (FMA-UE) scores had improved from 32.43 at baseline to 50.70 in the CR plus BMCG group and from 34.15 to 43.68 in the CR plus VDE group.

Improvements in secondary outcomes of upper limb function, grip strength (GS) and health-related quality of life (HRQoL) were also greater or achieved sooner by the CR plus BMCG group. At 1-month follow-up post-intervention, the mean Action Research Arm Test (ARAT) scores had increased from 26.00 at baseline to 42.23 among the CR plus BMCG participants and from 27.41 to 37.53 in the CR plus VDE group. While both groups demonstrated improvements in GS of both paretic and non-paretic sides as well as Mental Component Summary (MCS) scores, these improvements occurred at an earlier stage for CR plus BMCG participants, starting at mid-intervention (ie, 4 weeks) vs at 1 month post-intervention (ie, 12 weeks) in the CR plus VDE group.

“The mean difference improvements of 15.75 points, 14.95 points, 5.15 kg and 1.61 kg, 3.66 points and 5.3 points in the FMA-UE, ARAT scores, paretic and non-paretic grip strength, the Physical Component Summary [PCS] and MCS scores attained by the CR plus BMCG group reached the minimally clinically important difference values for subacute stroke, while the benefits of BMCG intervention for HRQoL were evidenced by the 9.69 percent and 11.24 percent improvements from baseline of the PCS and MCS scores, respectively,” highlighted the researchers.