Computer Methods and Programs in Biomedicine 151 (2017) 15–20

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Computer Methods and Programs in Biomedicine

journal homepage: www.elsevier.com/locate/cmpb

Motion Rehab AVE 3D: A VR-based exergame for post-stroke

rehabilitation
Mateus Trombetta, Patrícia Paula Bazzanello Henrique, Manoela Rogofski Brum,
Eliane Lucia Colussi, Ana Carolina Bertoletti De Marchi, Rafael Rieder∗
Universidade de Passo Fundo, BR 285 Km 292.7, Bairro São José, Passo Fundo, RS, Zip Code 99052-900, Brazil

a r t i c l e i n f o a b s t r a c t

Article history: Background and objective: Recent researches about games for post-stroke rehabilitation have been in-
Received 23 February 2017 creasing, focusing in upper limb, lower limb and balance situations, and showing good experiences and
Revised 13 July 2017
results. With this in mind, this paper presents Motion Rehab AVE 3D, a serious game for post-stroke reha-
Accepted 9 August 2017
bilitation of patients with mild stroke. The aim is offer a new technology in order to assist the traditional
therapy and motivate the patient to execute his/her rehabilitation program, under health professional
Keywords: supervision.
Stroke Methods: The game was developed with Unity game engine, supporting Kinect motion sensing input
Serious game device and display devices like Smart TV 3D and Oculus Rift. It contemplates six activities considering
Rehabilitation
exercises in a tridimensional space: flexion, abduction, shoulder adduction, horizontal shoulder adduction
Unity
and abduction, elbow extension, wrist extension, knee flexion, and hip flexion and abduction. Motion
Rehab AVE 3D also report about hits and errors to the physiotherapist evaluate the patient’s progress.
Results: A pilot study with 10 healthy participants (61–75 years old) tested one of the game levels. They
experienced the 3D user interface in third-person. Our initial goal was to map a basic and comfortable
setup of equipment in order to adopt later. All the participants (100%) classified the interaction process
as interesting and amazing for the age, presenting a good acceptance.
Conclusions: Our evaluation showed that the game could be used as a useful tool to motivate the patients
during rehabilitation sessions. Next step is to evaluate its effectiveness for stroke patients, in order to
verify if the interface and game exercises contribute into the motor rehabilitation treatment progress.
© 2017 Elsevier B.V. All rights reserved.

1. Introduction the affected hemisphere, being able to reach upper limb, trunk and
lower limb [5].
Stroke has often been described as a brain disease caused by The rehabilitation process consists a set of procedures to treat
the interruption of the blood supply to the brain, which can be the most of function lost by the patient, improving the functional
classified in two main types: ischemic or hemorrhagic [1]. It’s re- and intellectual capacities from neuroplasticity, and reeducating
sponsible for one death every 6 s [2], and the chance of having a motor and cognitive functions [6]. The use of various techniques
stroke approximately doubles for each decade of life after age 55. during therapy provides a better response to treatment, since the
Sometimes, this disease can affect individuals in the early age, in- process of adaptation and cortical reorganization of each patient
cluding young adults [3]. can happen in different ways. This way, it is necessary the con-
About 50% of patients who survived a stroke have limitations in stant use of new alternatives of treatment, without replacing those
the daily life activities, affecting their quality of life [4]. The stroke that already exist.
causes several motor and functional changes to the individual, like The goal of post-stroke rehabilitation therapies is to manipu-
paralysis on one side of the body. The most common paresis is late an interaction between motor recovery and cortical plasticity.
hemiplegia (total loss) or contralateral hemiparesis (partial loss) to However, as time goes by, patients tend to get tired and think the
training process is monotonous, which often leads to loss of mo-
∗
tivation for rehabilitation. According to Joo et al. [7], motivation is
Corresponding author.
E-mail addresses: trombetta.mateus@gmail.com (M. Trom-
one of the elements that have great influence in the plasticity of
betta), patriciabazzanello@hotmail.com (P.P. Bazzanello Henrique), the Central Nervous System (CNS), so it’s important to offer alter-
brum.manoela@gmail.com (M.R. Brum), colussi@upf.br (E.L. Colussi), natives of treatment that contemplate this factor. In this context,
carolina@upf.br (A.C.B. De Marchi), rieder@upf.br (R. Rieder).

http://dx.doi.org/10.1016/j.cmpb.2017.08.008
0169-2607/© 2017 Elsevier B.V. All rights reserved.
16 M. Trombetta et al. / Computer Methods and Programs in Biomedicine 151 (2017) 15–20
games for rehabilitation can increase motivation by offering a rich
and distinctive environment [8].
Looking for attractive, motivating and effective rehabilitation
techniques, technology has been highlighting [9]. According to Bar-
ros et al. [10], the use of digital therapeutic games in rehabilitation
centers are increasing. For the authors, such games are considered
very useful, since they allow therapy sessions to be customized ac-
cording to the abilities of each individual. Moreover, the capture of
natural movements enhances the motivation to perform the activ-
ities indicated by health professionals [11–14].
Considering the types of games available for rehabilitation, the
ones that stand out are the exergames. They have a stimulating
and interactive nature, explicit educational purpose and offer an
enriched environment of elements that motivate the learning of
motor skills [15,16].
Exergames that use motion sensors, such as Kinect, are able to
capture the patient’s natural movements, promoting a physical in-
teraction. They work as a virtual mirror, because they assist the pa-
tient in the perception of movements and can offer a visual feed-
back [13,17,18].The use of interactive devices makes the treatment
more encouraging, stimulating the human senses (mainly sight,
hearing and, in some cases, touch).
In the same perspective, Hocine e Gouaich [19] say that using
therapy with exergames, it is possible to provide instantaneous vi-
sual feedback, in addition to being a challenge to the patient. For
Barcala et al. [20], this visual feedback is an active way for the
motor control performance, and also benefits the motor learning
process, because it considers the stages of self-correction of the
executed movements, and benefits the neural plasticity of the pa-
tients.
With this in mind, our approach presents the first version of
Motion Rehab AVE 3D, an exergame for rehabilitation of post-
stroke patients with mild paresis. This game supports the motion
sensor Kinect and virtual reality devices. This paper is organized as
follow: Section 2 presents the game development. Section 3 shows
results and discussions of the pilot study of one of the game exer-
cises. Finally, Section 4 shows the conclusions and future work.
2. Methods
2.1. Development tools
The tools used for the development of the game Motion Re-
hab AVE 3D were: (1) Kinect for Windows SDK 2.0, (2) Unity game
engine to create the game interface, (3) Kinect V2 examples with
MS-SDK package and (4) the support for stereoscopic visualization.
Kinect is a device that recognizes body movements through a
camera with RGB video detection; a depth sensor; an infrared sen-
sor to capture spatial changes; and a microphone for voice com-
mands [21]. This way, it is possible to capture and map the patient
movements during the game.
Unity is a game development tool with a set of resources for
rapid development of interactive 3D or 2D applications using C #
or JavaScript [22]. It also support devices like Kinect and Oculus
Rift.
The Kinect V2 Examples with MS-SDK package, developed by
Adikari et al. [23], contains resources for mapping the user’s move-
ment for the virtual character in Unity. It supports Kinect 2.0, and
provides scripts that exemplify the integration of devices consider-
ing the user’s natural movements.
Regarding the visualization, this game supports the use of
HMD’s, such as Oculus Rift and HTC Vive. Through them, it is pos-
sible to use stereoscopy, a technique to create or improve the il-
lusion of depth from the analysis of two images, obtained through
binocular vision. This way, it is possible to explore the ability of
spatial perception and the sense of immersion and presence dur-
ing the interaction process [24]. If these devices are not available,
it is possible to use Smart TV’s 3D to simulate three-dimensional
space.
2.2. The game
The Motion Rehab AVE 3D is an exergame for the upper limb
motor and balance rehabilitation supporting patients with mild
stroke. For that, the game proposes an interactive way of encour-
aging patients to perform exercises that require spatial awareness.
The application also considers the importance of the ease of use
and clarity of information on the game interface.
It is important to emphasize that this software is an evolution
of the game created by Fiorin et al. [25] when the user interacts in
a 2D interface. This new version contemplates an immersive sce-
nario that explores the interaction with virtual elements scattered
within the patient’s range.
Another relevant point is that this project aims to offer a tool
to assist the upper limb motor function recovery process, cooper-
ating to the balance. These functions are related and have extreme
importance in the development of daily activities for post-stroke
patients.
It is also important to highlight that the stroke sequelae can
result in a diverse of implications depending on the type of brain
injury, severity, location and number of strokes. For this reason, it
is necessary to map particular disabilities of each patient, in order
to customize the rehabilitation process [1]. With this in mind, we
opted to develop a first version of this game considering activities
that can be executed by patients with mild paresis.
Motion Rehab AVE 3D (software registration number: BR 51
2016 001373 7, INPI - Brazilian Patent and Trademark Office) con-
templates different exercises in a 3D space: flexion, abduction,
shoulder adduction, horizontal shoulder adduction and abduction,
elbow extension, wrist extension, knee flexion, and hip flexion and
abduction. The aim is to simulate six activities (Fig. 1) in which the
patient must move his hands, upper limbs, lower limbs and trunk,
in order to get the objects and score. All activities developed for
the game contemplates exercises used in conventional physiother-
apy sessions.
Firstly, the user access a gesture-based menu to select some
level and difficulty to play, and an avatar to represent himself
(health elderly, male or female) during the game. The use of this
feature may improve, for example, proprioceptive stimuli and vi-
sual feedback during game interactions.
The game context consists of a character representing the
movements made by the player mapped in front of Kinect. On the
top of screen, it is informed the score, remaining time and level
difficulty.
In the first activity (Fig. 1a) the patient must stay in orthostasis
and perform shoulder abduction and adduction movements, elbow
and wrist extension, exercising the upper limb motor function.
In the second activity (Fig. 1b) the game explores the balance
and lower limbs. The patient must stay in orthostasis and perform
hip flexion movements to get the objects that falls from the top of
the scene with his feet.
The third activity (Fig. 1c) works with the upper limbs. The
patient must remain in orthostasis position and perform shoulder
abduction and horizontal adduction movements, along with elbow
and wrist extension, exercising also the upper limb motor function.
The fourth activity (Fig. 1d) exercises the lower limbs, where
the patient must remain in orthostasis and perform hip abduction
and adduction movements. This stage requires the patient to get
the objects with his feet.
The fifth activity (Fig. 1e) exercises the upper limbs, where the
patient stay in orthostasis position and performs shoulder flexion
movements in order to get the objects that fall in front of him.
 M. Trombetta et al. / Computer Methods and Programs in Biomedicine 151 (2017) 15–20
(A)
(C)
(E)
Fig. 1. Screenshots of the Motion Rehab AVE 3D exercises.
Finally, the sixth activity (Fig. 1f) involves an exercise of hip and
knee flexion, where the patient must get the objects with his knee,
training the balance.
Motion Rehab AVE 3D also monitors the player’s score. Hits and
errors are reported to the physiotherapist at the end of the activity,
in order to evaluate the patient’s progress. The interval between
each activity is two minutes to avoid muscle fatigue [26]. If some
exercise is not performed correctly (like forgetting to pick up a cor-
rect object), the game counts as an error.
Some researches evidence the possibility of effectively work-
ing the learning and training in the post-stroke rehabilitation pro-
cess. Noveletto et al. [28] evaluated the dynamic balance training
in post-stroke patients using a board with sensors to capture the
movements, with good results. Bosse et al. [29] emphasized the
standing balance training with different challenges for stroke pa-
tients with hemiparesis. In the case of Motion Rehab AVE 3D, if
the patient with a mild paresis presents some difficulty to execute
the planned activities in standing position, he/she can realize them
in seated position, since this posture does not interfere during the
capture of movements by the camera.
During the activities, visual feedbacks are displayed with infor-
mation about the score, user action (whether it is correct or not),
suggestions for how the activity should be done, and motivational
messages. In addition, alert and stimulating sounds are triggered
for each feedback presented. These resources are intended to stim-
ulate user attention and encourage him/her to easily complete the
task.
According to Garber et al. [30], it is recommended a patient
self-report to control the physical effort, and inform about his/her
physiological measures that may be being monitored. It is impor-
tant to highlight that a health professional (physiotherapist) and a
computer science team attended the game development.
17
(B)
(D)
(F)
3. Results
In order to test the game, a pilot study was conducted, consid-
ering the user interaction only the first activity of the game (Level
1, abduction movements and shoulder adduction, elbow and wrist
extension, to train upper limb motor function), in third-person.
Our initial goal was to map a basic and comfortable setup of
equipment in order to adopt later with post-stroke patients. There-
fore, we defined a study using two different visualization devices:
Smart TV 3D and HMD. We assumed that if healthy participants
are comfortable with a specific equipment configuration, this could
probably be replicated for post-stroke patients (considering the
same age range).
Our sample considered 10 healthy participants with ages be-
tween 61 and 75 years old, eight females and two males. Of these,
20% already had played some computer game and 10% related to
know one of the devices used in the test.
For the interaction process, we defined 30 s to perform the
tasks, avoiding a tiring experience. A two-minute interval were ap-
plied for rest between the uses of each equipment. Brum e Rieder
[27] questionnaire was used to collect the user preference data
(Table 1, 20 questions), using a 5-point Likert scale. We also in-
structed subjects to report verbally difficulties in relation to physi-
cal effort.
To balance the comparison half of the participants used, firstly,
the Oculus Rift (HMD) and after Smart T V 3D (T V), and the other
half in reverse (TV and HMD) - as shown in Fig. 2.
The following groups were defined for analysis:
• HMDTV: participants wearing the HMD, in the first experience,
and interacting with the TV, in the second experience;
• TVHMD: participants interacting with the TV, in the first expe-
rience, and wearing the HMD, in the second experience.
18 M. Trombetta et al. / Computer Methods and Programs in Biomedicine 151 (2017) 15–20

Table 1
Proposed questionnaire for 3D user interface evaluation.

N° Question

When I used the Oculus Rift...

1 I felt comfortable during the interaction in the game, using different equipment
2 I felt immersed, the interaction with the game was transparent, arresting my attention
3 I felt present within the virtual scene of the game, as if I were part of it
4 I felt good, the interaction with the game and the equipment did not cause discomfort, such as motion sickness, headache, dizziness or nausea
5 I felt oriented because the equipment provided a better visual perception of the 3D space
When I used the Smart TV 3D...
6 I felt comfortable during the interaction in the game, using different equipment
7 I felt immersed, the interaction with the game was transparent, arresting my attention
8 I felt present within the virtual scene of the game, as if I were part of it
9 I felt good, the interaction with the game and the equipment did not cause discomfort, such as motion sickness, headache, dizziness or nausea
10 I felt oriented because the equipment provided a better visual perception of the 3D space
About the 3D User Interface, it allowed...
11 To use and interact easily in the game
12 Clarity on the steps to be followed to perform the tasks in the game
13 Adequate and sufficient time for the execution of the tasks
14 Naturally to perform the tasks of the game, without difficulties
15 Easily to visualize, interpret and understand the interactive elements of the game (visual aspects)
16 To listen and assimilate easily the sound elements of the game
17 Easily to pick up objects in 3D space
18 To have a fun experience
Another questions
19 The theme of the game is associated with your age
20 Rest intervals during the experiment were sufficient

Table 2
Results for HA and HB hypotheses.

Hypothesis: questions U-value Z-score p-value Mean ± Std. Deviation

HA: Q1 x Q6 49,0 −0,04 0,97 4,60 ± 0,97 × 4,80 ± 0,42

HA: Q2 x Q7 49,0 −0,04 0,97 4,30 ± 0,67 × 4,20 ± 1,03
HA: Q3 x Q8 46,0 −0,26 0,79 4,60 ± 0,70 × 4,60 ± 0,97
HA: Q4 x Q9 44,0 −0,42 0,67 4,40 ± 1,35 × 4,90 ± 0,32
HA: Q5 x Q10 50,0 0,04 0.97 4,60 ± 0,97 × 4,60 ± 0,97
HB: Q11 11,0 0,21 0,83 4,60 ± 0,70
HB: Q12 10,0 0,42 0,67 4,90 ± 0,32
HB: Q13 10,5 0,31 0,76 4,00 ± 1,63
HB: Q14 11,0 −0,21 0,83 4,40 ± 1,26
HB: Q15 10,0 −0,42 0,67 4,90 ± 0,32
HB: Q16 12,5 0,10 0,92 5,00 ± 0,00
HB: Q17 9,5 −0,52 0,60 4,10 ± 1,20
HB: Q18 12,0 0,00 1,00 4,70 ± 0,67
HB: Q19 10,5 −0,31 0,76 3,60 ± 1,58
HB: Q20 12,5 0,10 0,92 5,00 ± 0,00

the evaluation compared HMDTV and TVHMD groups of 5 partici-

pants, and analyzed the remaining questions (11 to 20), which con-
sidered interface elements and the protocol adopted.

4. Discussions

We identified that 20% (four participants) presented some diffi-

Fig. 2. Participants during the task with HMD (left) and Smart TV 3D (right).
• We elaborated two alternative hypotheses to analyze the re-
sults:
• There is difference between using the HMD and the TV to play
the Motion Rehab 3D (HA, General);
• There is usability difference between the groups of the experi-
ment (HB, Group HMDTV x Group TVHMD).
The tests to evaluate HA and HB did not present statistically
significant results, rejecting the alternative hypotheses, as shown
in Table 2. In the HA’s case (U-critical = 23), the comparison con-
sidered the 10 participants and an analysis of the first 10 questions
(impressions about each device). In the HB’s case (U-critical = 2),
culties in terms of spatial orientation. They did not capture the ob-
jects proposed during the task because they did not perceive that it
was necessary to open their arms in a slightly larger angle (phys-
ically) to reach the objects. Another 20% (four participants) pre-
sented this same difficult in the beginning of the interaction pro-
cess – but, along of the experiment they perceived what should be
done and they were able to execute the test normally. None of the
subjects reported physical effort difficulties during the pilot study.
The tests also showed, subjectively, that visual and aural feed-
backs must be more intuitive to help in the user understanding
and cause more immersion. Moreover, we viewed the participants
present a greater ability to complete the task in third-person per-
spective. This shows, in the comparison between questions Q1 x
Q6 and Q4 x Q9, a small advantage in the sense of comfort for TV,
because this device offer a common type of visualization for these
 M. Trombetta et al. / Computer Methods and Programs in Biomedicine 151 (2017) 15–20
participants. In this way, it is recommended to use, initially, these
configurations with post-stroke patients in future evaluations.
On the other hand, it is noticed that the use of HMD offered
a better sensation of immersion to the user (Q2 x Q7), motivating
him to stay more attentive during the game. It may be interesting
to include the HMD in last rehabilitation sessions, after familiariza-
tion with TV by patients. However, this kind of device is more ad-
justed for interaction in first-person games. For this reason, a new
pilot study should evaluate this configuration (HMD + first-person
version) for our game.
Regarding our observations, 25% (five participants) presented
the best performance (hit everything) during the task, choosing
all the selectable objects and ignoring the distractors objects. On
the other hand, 20% (four participants) got terrible performance
(missed everything), not being able to hit any of the selectable ob-
jects. However, independently of the users’ task performance, all
the participants (100%) demonstrated very interest in exergames
and technologies projected for elderly. They classified the experi-
ence as interesting and beneficial to the age.
4. Conclusions
Exergames are increasingly gaining space in medical area, es-
pecially with the help of gesture and motion sensing devices and
immersive interfaces. Motion Rehab AVE 3D is presented as a new
tool for motor and balance rehabilitation. It will be used to help
physiotherapists in the motivation of patients during rehabilitation
sessions.
Regarding the pilot study, all participant classified as an inter-
esting and excellent experience for elderly age. We also suggested
to use the game in sessions with post-stroke patients, initially,
with a most popular visualization device (Smart TV 3D), in third-
person, since the participants felt a little bit comfortable during
the interaction process.
In addition, it is possible to evaluate the inclusion of a post-test
interview in the future, to identify elderly users’ preferences in de-
tail. Likewise, it may be noted that it would be interesting to offer
a version of the game in first-person, to allow greater sensations
of immersion and presence to the users, since HMDs have recently
become cheaper and accessible for the people. In short, we should
test again our game with a first-person version using HMD only.
For future work, we intend to continue the development of the
game and re-evaluate the software with post-stroke patients using
a protocol approved by the Local Ethics Committee. We also plan
to apply tests to patients who are in process of rehabilitation, to
verify if its use brings benefits to motor and balance aspects. Fi-
nally, we pretend to evaluate in association with different levels of
difficulty and physical effort executed by the patients during the
activities, including the use of physiological measures.
Conflicts of interest
None declared.
Acknowledgments
The authors are grateful to Brazilian National Council for Scien-
tific and Technological Development for their support.
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