Exercise Intensity During Interactive Video Games and Standard of Care of Individuals Post-Stroke
Phase: NA
Conditions: Stroke
Sponsor: Rutgers, The State University of New Jersey

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Title of Project: Exercise intensity during interactive video games and standard of care of individuals 
post-stroke
Principal Investigator: Judith Deutsch, PT PhD
Funding Source(s): QED Science Center
1.  
Purpose/Specific Aims
1.1 Objectives
To compare exercise intensity and enjoyment for persons post-stroke using customized 
video games (VSTEP), off-the-shelf video games (Kinect) and standard of care. 
1.2 Hypotheses
We hypothesize that for persons post-stroke, exercise intensity, performance and 
enjoyment will be superior when participating in the VSTEP games, followed by standard of care 
and  off-the-shelf games.
2.      Background and Significance
The levels of physical activity among individuals post-stroke in the chronic phase rarely meet the 
recommendations of physical activity to promote health and for cardiovascular fitness. There is some 
evidence that activity-promoting video game (AVG) technologies promote physical activity . Off-the-
shelf AVG consoles like the Microsoft Xbox with the Kinect sensor have been shown to enhance body 
movement and energy expenditure for healthy individuals and recent research has shown promise for 
individuals post-stroke. (Kafri, 2014) Off-the-shelf games are not designed for rehabilitation and often are 
too difficult for persons post-stroke. The VSTEP, consists of a series of mini games developed in the 
RIVERS lab for rehabilitation for balance, mobility, coordination, and fitness. They are customized to the 
users abilities and therefore may be better suited for persons post-stroke. This study will determine the 
differences in exercise intensity, performance and enjoyment levels while individuals post-stroke use the 
VSTEP compared to the off-the-shelf Xbox Kinect games and standard of care. 
3.     Research Design and Methods
Overview of study design: The proposed study will use an experimental cross-sectional design. It 
will be conducted in one session. During the first part of the session participants will be familiarized with 
the games.  The second part of the session will have participants play interactive video games and 
perform mobility tasks. During this session data of energy expenditure and enjoyment of activity will be 
collected. 
3.1. Duration of Study
Each subject will participate for approximately 2 hours.
3.2 Study Sites
RIVERS Lab SSB 723 or SSB 920
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3.3 Sample Size Justification
This is a pilot trial and therefore will enroll 15 subjects. This number is comparable and 
in fact exceeds published articles in the  neuro rehabilitation field.
3.4 Subject Selection and Enrollment Considerations
3.4.1 Inclusion Criteria
Participants will be men and women who will have sustained a stroke at least six 
months before enrolling in the study and will be between 19 and 80 years old. They will 
be able to ambulate 100 feet without physical assistance but allowed to use assistive 
devices and orthotics, and able to stand for 3 minutes. They will be screened for inclusion 
with the PARQ.  
3.4.2 Exclusion Criteria
1.
A history of severe heart disease, heart attack, valve replacement or 
coronary artery bypass surgery, severe lung disease, uncontrolled 
diabetes, traumatic brain injury or neurological disorder other than 
stroke.
2.
Are unable to follow directions.
3.
Do not have adequate vision and hearing ability (either aided or unaided 
with glasses, contacts or hearing aids)
4.
Are unable to sign a consent form.
5.
Unstable medical condition or musculoskeletal disorder such as severe 
arthritis, knee surgery, hip surgery, or any other condition that the 
investigators determine would impair the ability to perform the required 
stepping for the games presented.
6.
Any other medical condition contraindications to exercise.
3.4.3 Subject Recruitment
Participants will be recruited by flyers and contacting previous participants in the 
RIVERS Lab studies who have agreed to be contacted for future studies. Recruitment 
flyer has been uploaded separately for ease of stamping. The email will be sent once the 
IRB approval is obtained to participants, both clinicians and persons post-stroke who 
have been involved in previous studies and expressed an interest in being contacted for 
future studies.
3.4.4 Consent Procedures
The study will be explained to the potential subjects by the Principal Investigator 
or co-investigators, the consent will be read, and the potential subject’s questions will be 
answered. If they wish to enroll, the subjects will sign the consent form. The study staff 
obtaining consent will also sign and date the consent form, and a copy will be given to 
the subject.
3.4.5 Subject Costs and Compensation
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There is no cost for participating this study. A $30.00 honorarium will be 
provided for participation.
3.5 Chart Review Selection There are no charts to review.
4. Study Variables
4.1 Independent Variables or Interventions 
The independent variable is type of exercise with four levels: VSTEP(random), VSTEP 
(repeated) Kinect and Standard of Care.
•
VSTEP: a custom designed video game that utilizes the motion sensor hardware of the 
Xbox Kinect to track the movements of the user whose feet are represented on the game 
screen. The object of the game is for the subject to step from a center square to another 
target square that appears around the perimeter using the appropriate foot.  A variation of 
the game consists of the user marching in place to “kick” soccer balls that appear on 
screen.  The VSTEP is game paced but calibrated to the user as the targets will switch at 
a rate customized to the subject. It will be played in two modes

VSTEP random

VSTEP repeated
•
Kinect: A mini game called "Light Race" from the off the shelf game for the Xbox Kinect 
titled “Your Shape: Fitness Evolved.”  The game consists of one minute rounds in which 
the user steps on lighted tiles.  The user is represented on screen as standing in the middle 
of a circle of tiles that light up, which the user must step on with their avatar before they 
disappear.  Subjects will also perform stepping tasks interspersed between rounds of 
gameplay.  
•
Standard of Care (SOC): A stepping task designed by the authors to represent a practical, 
comparable intervention that may be used by clinicians to treat patients with stroke in a 
rehabilitation setting.
4.1.1 Drug or Device Interventions: N/A
4.2 Dependent Variables or Outcome Measures
The dependent variables will include measures of exercise intensity, performance, and 
enjoyment for each of the types of exercise.  Additional measures will be taken to determine 
readiness for physical activity and to characterize lower extremity sensorimotor function.
•
Exercise Intensity: HR, VO2, Rate of Perceived Exertion (RPE)
•
Performance: Accuracy (Kinect and VSTEP), Total Steps (SOC)
•
Enjoyment: Physical Activity Enjoyment Scale (PACES)
•
Fugl-Meyer Assessment of Lower Extremity Function
4.3 Risk of Harm
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There is minimal risk associated with participating in this study. You may experience 
neuromuscular fatigue or loss of balance. There will be a clinician who is part of the study team 
on site to decrease the chance of any harm.
4.4 Potential for Benefit
There is no direct benefit from participating in this study. However, the information 
gained may be used to develop relevant and useful games for rehabilitation.
5.   Data Handling and Statistical Analysis
Statistical analysis on the data gathered will be performed using a Repeated Measures ANOVA to 
compare differences in energy expenditure (METs) and a Friedman test to compare participant feelings’ 
of enjoyment in each subject for the three interventions. An alpha level of .05 will be set for all analyses. 
There may also be blocked comparisons between VSTEP repeated and SOC, and VSTEP random and 
Kinect. These will employ paired t-tests.
6.      Data and Safety Monitoring: Study is minimal risk.
7.      Reporting Results
7.1 Individual Results
Data collected on the individual will be summarized into a table for easy to read purposes 
with a brief narrative of their results.  On selected occasions there may be instances where a 
single subject is of great interest and that data may be represented as a case report.  
7.2 Aggregate Results
Aggregate results will be shared in the form of a summary paper with all the participants 
via email.
7.3  Professional Reporting
Data from this study will be communicated in poster format and then in a paper format 
and at a virtual reality society or rehabilitation meeting.   
8
Bibliography:  
Kafri M, Myslinski MJ, Gade VK, Deutsch JE. Energy expenditure and exercise intensity 
of interactive video gaming in individuals poststroke. Neurorehabilitation and neural 
repair. 2014;28(1):56-65.
Kafri M, Myslinski MJ, Gade VK, Deutsch JE. High metabolic cost and low energy 
expenditure for typical motor activities among individuals in the chronic phase after 
stroke. Journal of neurologic physical therapy : JNPT. 2014;38(4):226-232.
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