Effects of a Video Game-Based Intervention on the Attention and Functional Independence of Older Adults after Cerebrovascular Accident

52 Mailing address: Magliani Reis Fiorin Martel – Rua Dom Pedro II, 6, bloco B, apto. 404 – Ijuí (RS), Brasil – CEP: 98700-000 – Telefone: (55) 9947-0372 E-mail: maglifiorin@yahoo.com.br – Financing source: Fundação de Amparo à Pesquisa do estado do Rio Grande do Sul e Conselho Nacional de Desenvolvimento Científico e Tecnológico, Edital MCTI/CNPQ/Universal 14/2014 – Conflict of interest: Nothing to declare – Presentation: Feb. 2015 – Accepted for publication: Dez. 2015 – Approved by the Ethics Committee of Universidade de Passo Fundo no 605.652/2014. DOI: 10.1590/1809-2950/14643623012016


INTRODUCTION
We are currently experiencing a period marked by numerous transformations and technological advances.The quest for a more active and healthy lifestyle has stimulated various studies focusing on the older adults population and technologies as enablers of innovative experiences, such as the use of video games to stimulate the brain 1 .
The emergence of new forms of rehabilitation with the use of video games has become a strong ally of health professionals, especially those directly involved in rehabilitation.The use of such technology has boosted intervention not only in healthy subjects, but also as a motivation strategy in treating patients with conditions resulting from a neurological injury, such as a cerebrovascular accident (CVA).
CVA is described as a cerebrovascular disease caused by the interruption of blood flow to the brain, and can be classified according to the presence of hemorrhage or ischemia.The interrupted supply of oxygen and nutrients causes injury to the brain tissue, provoking sequela 2 .
Every year, 15 million people worldwide suffer a CVA.Of this total, five million die and another five million become permanently incapacitated, evidencing that the number of CVAs continues increasing due to aging 3 .
Among the main interventions for the rehabilitation of motor sequela, researchers have included the use of technology in their protocols.The most employed and efficient proposals to treat motor alterations caused by CVAs involve Constraint-Induced Movement Therapy (CIMT), biofeedback, motor imagery, and roboticassisted gait training 4 .
Video games are considered a complementary tool in rehabilitation and have been a frequent focus of research and practice in the past few years.However, proof of their efficacy among older adults is still scarce 5 .
In the study by Anguera et al. 6 , video games were used with 46 adults aged 60 to 85 years over four weeks, adding up to a total of 12 hours.The authors reported that this type of intervention can be useful to evaluate the cognitive reserve of this population.More specifically, the researchers affirmed that a subject's performance in a specific video game may be a sign of cognitive decline.
On the other hand, this same method contributes to improve sustained attention and memory in the short term.These results are ratified by other authors who also affirm that the use of video games has a direct influence in the development of cognitive functions 7 .
Intervention with virtual environments in CVA rehabilitation may vary, since the objectives may range from training a specific movement to improve a particular motor skill, such as placing a cup of coffee on the table, to more advanced activities with physical objects within virtual environments 8 .In both cases, qualified professionals must elaborate a treatment plan with the use of video games.It is necessary to establish relevant strategies for each individual case to cater for special needs that may involve associated risks not present in other subjects without the same pathology 9 .
Within this context, other researchers show that the use of virtual environments in the rehabilitation of patients with CVA sequela is capable of achieving significant results in tests assessing cognition, gait, balance, motor control, and perception 10,11 .In addition, the use of technology is a motivating and differentiated alternative for patients in CVA rehabilitation.
Given this scenario, it is necessary to address both cognitive and motor aspects in the rehabilitation of CVA patients.With this perspective in view, the objective of this study was to investigate the effects of intervention with a video game on the attention and functional independence of older adults who had suffered a CVA.The hypothesis tested was that intervention with video games can improve attention and functional independence in these older adults.For this study, the video game Motion Rehab was developed in partnership with the Computing Science course of the University of Passo Fundo, Rio Grande do Sul, Brazil.

METHODOLOGY
This is a quasi-experimental quantitative study with pre-and post-control intervention.

Ethical considerations and sample
The research was approved by the Research Ethics Committee of the University of Passo Fundo, according to Resolution no.466/2012 of the Brazilian National Health Council, opinion no.605.652/2014.All individuals participating or persons responsible signed a free and informed consent form.
Ten older adults of both sexes took part in the study, complying with the following inclusion criteria: 60 years old or more; no serious cognitive impairment or dementia; no depression symptoms; defined CVA diagnosis in acute or chronic stage; impairment in left or right side of ischemic or hemorrhagic origin; and attending regular physical rehabilitation at the Regional Center for Physical Rehabilitation of Giruá, Rio Grande do Sul, Brazil.The older adults participating in the intervention with the video game continued their conventional physiotherapy treatment, according to the methodology adopted by the health care institution, with specific Bobath techniques.

Instruments
To investigate the inclusion criteria, the following instruments were used: 1) Mini Mental State Examination: capable of screening/identifying dementia.It verifies the integrity of cognitive functions: space-time orientation, memory, attention, calculation, language and constructional praxia 12 .The cut-off points of the version validated for the Brazilian population by Bertollucci et al. 13 and improved by Brucki et al. 14 were used, which are: illiteracy -19 points; 1 to 3 years of schooling -23 points; 4 to 7 years -24 points; and over 7 years of schooling -28 points 13 .2) Geriatric Depression Scale: tool to diagnosis depression symptoms.It is widely used in studies involving older adults, with a cut-off value above five points 16 .The scale was used to evaluate the presence of depression, which could impair the individuals' level of attention during the execution of the video game.It was administered by a professional psychologist.
Data was collected at two different moments, preand post-intervention, with the use of the following instruments:

The Motion Rehab video game
The video game (industrial property registration number BR 51 2014 001087-2) was developed based on a protocol prepared by the researcher containing the following exercises: shoulder flexion and abduction; elbow extension; hip and knee extension and flexion.
It takes 15 minutes, with activities distributed into four phases (Figure 1 and 2), based in the main limitations caused by CVA and considering different methodologies available for the physical and cognitive rehabilitation of this injury.Phase 1 involves exercises for the upper limbs with subjects sitting on a chair (five minutes).Phase 2 involves sitting and standing exercises, with subjects looking for the objects with their head (three minutes).Phase 3 involves exercises with upper limb movements and slight torso rotation, with subjects standing (four minutes).Phase 4 combines all previous exercises in one (three minutes).
The setting of Motion Rehab is a dance for older adults, with music typically played at this kind of leisure event.The subject must move his hand or head in the direction of objects that correspond to the game's theme, scoring points when successful.Distractors (objects unrelated to the context) appear among these objects, making subjects lose points when they are touched.
Video games used in rehabilitation offer different levels of difficulty.Normally, the game is more difficult when the execution pace is faster and easier when the pace is slower 18 .The configurations provided by Motion Rehab include level of difficulty, consisting of increasing the speed with which objects appear on the screen.
The game was developed with Microsoft Visual Studio 2010 IDE, XNA 4.0 framework and Kinect for Windows SDK 1.7 library for use of the Kinect movement sensor.It was created in partnership with the Computing Science course of the University of Passo Fundo, Rio Grande do Sul, Brazil.

Procedures
Initially, the instruments to assess inclusion criteria and data collection were administered.
The intervention sessions were held individually once a week, over a period of 15 weeks, totaling 15 sessions.Subjects remained with the researcher for a total period of 45 minutes, allowing time to check vital signs (blood pressure, heart rate and oxygen saturation) at the beginning and end of the session and for their movement requirements.The participants also continued with their normal treatments.
All intervention sessions were supervised by the researcher responsible for the study.
The older adults interacted with the Motion Rehab video game via a 32" TV connected to a computer and the Kinect movement sensor (located below the TV), a device that recognizes human body movement through a camera with RGB video capture; a depth sensor; an infrared sensor to capture spatial movement; and a microphone for voice command.
All participants were reassessed after the final session.

Data analysis
Data were captured on a Microsoft Excel table and the statistical analysis was performed with the aid of SPSS 17.0 for Windows.Numerical variables were expressed as average ± standard deviation or median (percentile 25 -75) according to normal or non-normal distribution, and categorical variables as absolute and relative frequency.Pre-and post-intervention comparisons were executed using Student's t-test for paired samples.Tests with a probability value of < 0.05 were considered statistically significant.

RESULTS
Table 1 shows the socio-demographic and identification characteristics of the participants' clinical aspects.Of the total number of participants, whose average age was 67.7±7.1, five (50%) were male and five (50%) were female, nine (90%) of them married.Regarding residence, 9 (90%) lived in the urban area; among these, the prevailing profession prior to the CVA was agriculturist -five (50%).We should stress that before the CVA most of them lived in the rural area, but the need for medical care and regular treatment forced them to move to the city.
Regarding the clinical factors of the brain injury, ischemic CVA was more prevalent, affecting eight (80%) of the older adults, and the most injured brain side was the right one, affecting five (50%) of them.Comparing pre-and post-intervention attention and functional independence, statistically significant results were observed, as described in Table 2. Regarding the functional independence evaluated by the FIM test, the total result evidenced statistically significant differences following intervention with the video game.In pre-intervention, the score was 102.3 ± 23.4, indicating modified or assisted dependence, i.e., the need of another person for supervision or physical help to perform the activity; and in post-intervention, the score was 107 ± 18.6, indicating modified independence, in which the activity requires technical help, adaptation, braces, high execution time or cannot be executed with complete safety 15 .
Another important point observed was related to attention (Trails Test -Form 2) and interference.We identified an improvement of the divided attention of the older adults, since the test execution time was reduced from 330.5 ± 140.8 to 259.4 ± 112.5 seconds, and interference by the professional psychologist also fell, from 0.8 ± 0.5 to 0.4 ± 0.3.Furthermore, one of the recurrent concerns of physical therapists working with cognitive and motor rehabilitation has been patients' adherence to treatment, mostly on a long-term basis.The study developed with the use of a video game relates to the perspective of designing new approaches to diversify treatment, making it more attractive and efficient with the use of computer resources 21 .
The results of the video game-based intervention in older adults with CVA sequela confirms, alongside the other studies, that it was possible to contribute to the motor and cognitive evolution of participants demonstrated in the Trails Test Form 2 (divided attention) and the Functional Independence Test (FIM).

CONCLUSION
With the research concluded, it was possible to ascertain that interventions with video games can be used safely and efficiently in post-CVA rehabilitation.The results obtained strengthen the hypothesis that the Motion Rehab game has proven to be an additional form of efficient rehabilitation.
However, it is still necessary to evaluate the use of the Motion Rehab game with a larger number of older adults suffering from CVA sequela.A suggestion for future studies is implementing the protocol only among patients of hemorrhagic CVA, since those with ischemic CVA were prevalent in this study.

Figure 1 .Figure 2 .
Figure 1.Phases of the Motion Rehab video game

Table 1 .
Socio-demographic characteristics of the studied population (n=10)

Table 2 .
Pre-and post-intervention functional independence and attention