Feasibility of the AHA Exergame System in Parkinson's Disease Patients
Condition: Parkinson Disease
MeSH terms: Parkinson Disease
Study type: Interventional

Summary: 
      Background: Parkinson's disease (PD) remains a progressive disease associated with a high
      level of disability. Due to the physical and cognitive impairments, fatigue and apathy,
      patients frequently experience a decrease in their daily physical activity. Exercise programs
      have been recommended for symptomatic control, however, its implementation is still
      challenging in terms of acceptability and adherence. Exergames (i.e. exercise based on video
      games) have been proposed as a potential, home-based rehabilitation tool to improve PD
      patients motor skills and to promote a more active lifestyle.

      Methods: This study aims to evaluate the feasibility and safety of an exergames system design
      for PD patients' rehabilitation. A mix-methods study, including two focus groups (with
      patients and physiotherapists) and quantitative feasibility study, will be performed.
      Physiotherapists and PD patients with a Hoehn Yahr Stage ≤ 2 (MED ON), ability to walk
      independently without risk of falling and a Mini-mental state score > 24 will be included.
      The primary outcome will be patients' satisfaction with the games measured through a 7-point
      Likert scale. Secondary outcomes will include games difficulty (7-point Likert scale),
      perceived effort (modified Borg scale), safety (number of adverse events) and functional
      mobility (Time up and Go test).
    

Detailed description: 
      1. Background Parkinson's disease (PD) is a neurological disorder, characterized by the
           presence of motor and non-motor symptoms that negatively affects patients' quality of
           life. (1,2) Despite optimal medical treatment, patients develop a progressive disability
           that usually shapes a sedentary lifestyle, which is a risk factor for cardiovascular
           disease, diabetes mellitus, cognitive impairment, osteoporosis, and depression. (1,3,4)
           In the past years, physiotherapy and exercise have been recommended for symptomatic
           control and as a strategy to reverse PD patients' sedentary lifestyles. (2,5) However,
           results from previous studies showed that physiotherapy programs only provide a
           short-term benefit and it still a challenge the implementation of unsupervised
           home-based exercise. (3,6) Exergames are video games to exercise, based on gross
           physical movements of the player, that combine real-time motion detection with engaging
           games. (7,8) They have been described as a therapeutic tool that includes functional,
           purposeful and appealing exercise, with positive effects in neurological diseases and
           older adults. (7,8) Exergames promote an integrated motor and cognitive stimulation,
           providing biofeedback, enhancing game performance and learning of the virtual tasks with
           transference to real conditions and its home-based characteristics. Based on this,
           exergames have been proposed as a complement to physiotherapy programs, in order to
           improve PD motor symptoms. (7,8) However, they should be specifically tailored to
           address PD functional needs, in order to optimize efficacy, adherence, and safety. (8)
           This study aims to evaluate the feasibility and safety of an exergames system design for
           PD patients.

        2. Participants and methods

           Study design A feasibility study including two phases, one qualitative and another
           quantitative will be performed.

           In the first phase, the qualitative study, two focus groups will be conducted (one with
           PD patients and other with a group of physiotherapists), to discuss the accessibility
           and usability of the exergames to be tested and the exercise-based computer games for
           people with PD. The second phase, the quantitative study, will be a single-center,
           open-label, feasibility, and usability study.

           Patients recruitment PD patients will be recruited from the Campus Neurológico Sénior
           (CNS) institution to participate either in the qualitative phase or in the quantitative
           phase. Patients will be included if they were: 1) idiopathic PD patients according to
           the UKBB criteria; 2) age between 40-80 years old; 3) with a Hoehn Yahr Stage (HY) 1 or
           2 in MED ON; 4) ability to walk independently without risk of falling; 5) a Mini-mental
           state score > 24; 6) ability to communicate with the investigator, to understand and
           comply with the requirements of the study; and lastly 7) ability to provide written
           informed consent to participate in the study.

           Patients will be excluded if they had an atypical parkinsonian syndrome.
           Physiotherapists will be also screened and recruited from the CNS institution. The Local
           Ethical Committee approved the study (Ref. 9/2017). All included patients and
           physiotherapists will provide informed consent, before enrolling in any study procedure.

           Intervention and assessment The AHA Exergame System consists of a mobile computing
           platform running a set of parameterizable exergames purposely designed for elderly
           fitness training. The platform is equipped with a 1000 lumens video projector capable of
           creating a 2.05m by 1.16m floor projection display and a Kinect V2 sensor to serve as
           game controller.(9) The AHA exercise-based computer games have been designed for and
           tested with elderly people and were adapted for the functional limitations of PD
           patients. The system includes five different games that aim to train patients motor
           ability, cardiorespiratory and muscular strength.

           Patients Focus groups The focus group will be conducted using a semi-structured script
           where participants will be asked to discuss their thoughts on Exergames, daily use of
           technology and preferences for the style and type of games.

           During the session, participants will be invited to view and play with the five games to
           have their perception of the appropriateness of the games for people with PD. This part
           of the focus group will be followed by a member of the IT team and a physiotherapist to
           provide support for instructions guidance and to guarantee the participant's safety
           while trying the games. In the end, patients will be asked to share their thoughts on
           which features they would like to see included in the proposed games.

           The focus group will be recorded, with the agreement of all participants, to be
           transcribed for inductive thematic qualitative analysis.

           Physiotherapists focus groups The focus group will be developed using a semi-structured
           script where the physiotherapists' participants will be asked for their opinion on
           Exergames, the usability of this tool during the sessions, advantages, and
           disadvantages.

           During the focus group, physiotherapists will be invited to play the games to comment on
           the features presented and its adequacy to PD patients. At this point, a member of the
           IT team will provide support at a technical level and for instructions guidance.

           The focus group will be recorded, with the agreement of all participants, to be
           transcribed for inductive thematic qualitative analysis.

           Quantitative study Baseline assessment Before any data will be recorded, each patient
           reviewed and signed an informed consent form. In order characterize the sample,
           demographic data (date of birth, age, gender, height, weight) and medical history (age
           of onset, disease duration, medication) will be collected, and three rating scales and
           clinical tests (MDS-UPDRS, HY and Time Up and Go (TUG) test) administered.

           Intervention Participants will be invited to play the five different Exergames. Before
           playing the games, each participant will have a training period, in which the game will
           be presented, and the instructions explained. The sequence in which the games will be
           played will be randomized using computer software. Each game will be played for a total
           time of 5 minutes. In the end, patients will rate their satisfaction with the game and
           its difficulty through a 7-point Likert scale and the perceived exertion through a
           modified Borg scale. At the end of the intervention, the TUG test followed by the
           modified Borg scale will be repeated.

           Exergames overview

           Grape Stomping (Douro Region) - Cardiorespiratory Training The goal of this Exergame is
           to stomp on grapes, pulled from the conveyor belt into the tank by dragging small
           virtual grape baskets. To do that, flexion-extension arm movements are needed to drag
           the grape bunches into the tanks, once done, the stomping process starts, requiring
           users to raise the knees to a pre-defined height to produce the wine. After fill up one
           of the tanks, users are asked to move to the others to continue the exercise. The
           experience ends once the pre-established training time finalizes, thus screening the
           number of tanks filled, the number of litres of wine produced, the number of steps
           performed and the number of grape bunches dragged.

           Rabelos VR (Porto City) - Upper limbs, Muscular Strength Training The goal of this
           Exergame is to row along the river collecting several wine barrels located in small
           docks at the river banks. Users are encouraged to make circular arm movements simulating
           rowing gestures to move the boat forward. For the lateral displacements of the boat,
           users can be standing and use lateral movements or trunk leaning; or they can be seated
           using trunk leaning. Additionally, to navigate the treacherous rapids, users have to
           avoid big rocks randomly located in the riverbed while trying to dock on the margins to
           pick up one or multiple wine barrels. To do that, users must turn the trunk to the side
           of the dock and make an extension-flexion movement of the elbow to simulate picking up
           the barrels. Meanwhile, the boat is stopped until users picked up, one by one, all of
           the barrels in the docks and subsequently the users should The Exergame ends with the
           countdown of the pre-established time, screening the number of rocks hit, completed rows
           and collected barrels as well as the time spent rowing and collecting.

           Toboggan Ride (Madeira Island) - Balance, Trunk Muscular Strength The main goal in this
           Exergame is to successfully collect as much objects as possible in a pre-established
           time avoiding crashes with cars and pedestrians. The sledge direction is controlled via
           trunk lateral flexions to the right and to the left while the acceleration is controlled
           through trunk flexion-extension movements. Flexion movements are used to increase the
           acceleration of the vehicle while extensions are used to deaccelerate it. Collecting and
           crashing events occur when the virtual vehicle make a collision with each individual
           object making specific rewarding/punishment game sounds. The journey finalizes with a
           screenshot of metrics encompassing the time of the session and the number of objects
           collected.

           Exerfado (Lisbon City) - Lower Limbs, Muscular Strength Training The main objective is
           the user to collect each musical note by positioning him/herself in front of the note
           trajectory. Additionally, the user needs to "push" wrong notes that are sliding in the
           wrong trajectory and then collect them equally at the right position. Collecting the
           right notes at the right position will reward the user by incrementing the percentage of
           notes collected. Some notes are special and offer extra bonus, they are identified in
           the game with a glowing and sparking effect. The wrong notes are displayed in game with
           black color and with a blinking arrow indicating the direction to where needs to be
           pushed, if the user is able to perform the correct arm gesture before the musical note
           is lost, the wrong note changes to the correct trajectory and to the right color. Notes
           are pushed with arm extension which can be predefined as low or high. User has to move
           left and right within the projection range. A piano key is represented as "pressed" when
           the user is in front of it and indicates that a note coming in that trajectory will be
           collected. User position can be tracked by the waist joint or by both feet; in this case
           the user will be able to select two piano keys at the same time. Interaction ends when
           the music stops playing.

           To better adapt to each user needs, on the configuration menu is possible to change
           settings such as arm extension, joint to be tracked, the percentage of notes, note
           sliding time, and musical choice from a list.

        3. Statistical methods and data analysis

           Sample size

           Qualitative Study For the focus group, 5 PD patients will be invited to participate in
           the qualitative study. For the physiotherapist approach, 5 participants will be invited
           with experience in dealing with PD patients.

           Quantitative Study Assuming this is an exploratory study, there is no rationale to
           estimate the sample size, a total of 10 participants will be asked to participate in the
           quantitative phase, with the condition they did not take part of the qualitative phase.

           Data Analysis A content analysis will be performed on the qualitative data assuming a
           deductive approach. The content analysis will be performed using a descriptive and
           interpretative analysis of the focus group.

           The statistical analysis for the qualitative phase of the study will be performed using
           SPSS® version 21.0; SPSS Inc. Chicago, IL. Data will be described using descriptive
           statistics.

           As our primary outcome, we will measure patients' satisfaction with the games, through a
           7-point Likert scale, at the end of each game and at the end of the intervention (global
           perspective).

           The secondary outcomes will be:

             -  Patients level of difficulty with the game measures through a 7-point Likert scale;

             -  Changes in the level of perceived exertion measure at the end of each game and from
                baseline to end of all games with the modified Borg scale;

             -  Number of adverse events;

             -  Changes in the TUG test result from baseline to end of the intervention.

        4. Safety issues and adverse events reporting Adverse events will be collected for the
           duration of the study and at the Follow-Up visit. It is not expected that participation
           in the study will be associated with risks or will increase the risk of adverse effects.
           All therapeutic interventions will be recommended to be kept stable.

           Research subjects will be questioned about adverse events during the Clinical Assessment
           and follow up visit. All adverse events (serious or non-serious) and any other abnormal
           clinical findings will be recorded in the subjects' case report form (CRF). For all
           adverse events, sufficient information will be pursued to permit:

             -  a determination of a temporal relationship;

             -  an adequate determination of the outcome of the event (i.e., whether the event
                should be classified as a serious adverse event);

             -  an assessment of the causal relationship between the adverse event and the study
                requirements.

           An abnormal result finding will be classified as an adverse event if one or more of the
           following criteria are met:

             -  The resulting finding leads to discontinuation of subject participation in the
                research study;

             -  The resulting finding is considered an adverse event by the researcher.

        5. Withdrawal of subjects Subjects will be able to withdrawal from the study at any time of
           the research study. After withdrawal, no more data will be collected and taken into
           consideration for statistical purposes regarding the withdrawal subjects.

      Withdrawal criteria will include, for example: adverse events (serious and non-serious), lack
      of compliance to testing, subject fails to comply with protocol requirements, subject's
      voluntary withdrawal of consent.

      Replacements will not be considered.
    

Intervention name(s): AHA Exergame System
Intervention type(s): Device
Intervention description(s): The AHA Exergame System consists of a mobile computing platform running a set of parameterizable exergames purposely designed for elderly fitness training. The platform is equipped with a 1000 lumens video projector capable of creating a 2.05m by 1.16m floor projection display and a Kinect V2 sensor to serve as game controller. The AHA exercise-based computer games have been designed for and tested with elderly people and were adapted for the functional limitations of PD patients. The system includes five different games that aim to train patients motor ability, cardiorespiratory and muscular strength.
Intervention model: Single Group Assignment
Intervention model description: A mix-methods study, including two focus groups (with patients and physiotherapists) and quantitative feasibility study, will performed. Physiotherapists and PD patients with a Hoehn Yahr Stage ≤ 2 (MED ON), ability to walk independently without risk of falling and a Mini-mental state score > 24 will be included. The primary outcome will be patients' satisfaction with the games measured through a 7-point Likert scale. Secondary outcomes will include: games difficulty (7-point Likert scale), perceived effort (modified Borg scale), safety (number of adverse events) and functional mobility (Time up and Go test).
Masking: None (Open Label)
Primary purpose: Device Feasibility
Keywords: Parkinson's disease; Exergames; Virtual reality; Exercise; Feasibility study