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High Intensity Exer-Gaming

17 March 2021

In this article, Ian Slater discusses Exer-Gaming and its effect on stroke patients as we move into an age where the delivery of remote therapy and virtual rehab becomes more prevalent.

By way of ‘teaser’ on 28th April I have the pleasure of conducting a live webinar with David Fried of Evolv. I have known David for several years after he was kind enough to invite me to his Shoreditch offices to view the first generation of  Evolv’s CE marked virtual therapy platform called VirtualRehab (now rebranded as EvolvRehab®). It still ranks as one of my best days as a lawyer: largely because it had absolutely nothing to do with the law and everything to do with seeing a vision for the future of rehab which matched my own.

David exhibited the EvolvRehab platform at ACRM’s Dallas conference in 2018 (for anyone old enough to remember those were the days when we had real live conferences). For those of you who have followed this blog for some time you will know that I was the first UK lawyer (and probably still one of only a handful) to be accepted as a member of the American Congress of Rehabilitation Medicine.

There will be more about RehabKit and virtual rehab to come over the next few weeks in the lead up to the webinar but for the time being I was catching up on back issues of ACRM’s ‘Archives of Physical Medicine and Rehabilitation’ when I came across some interesting original research published in the January edition: ‘High Frequency and Intensity Rehabilitation in 641 Subacute Ischaemic Stroke Patients’ APMR 2021; 102: 9 - 18.

This was a pseudorandomised controlled trial undertaken in Hungary between 2014 - 18 with 641 participants. The general purpose was to determine and compare the effects of an unusually high intensity / frequency exergaming mobility rehabilitation program on clinical symptoms such as blood pressure, mobility and quality of life.

Accepting that the focus of this research is in relation to stroke patients there is, and has for several years now, been a trend towards moderate intensity rehabilitation exercise in a number of patient groups to include not only stroke patients but, also, Parkinsons, multiple sclerosis and, more pertinently for the insurance industry, spinal cord and brain injured patients. It will be interesting to see, therefore, whether or not the results can be translated to general applicability in the TBI and SCI populations: logically I cannot see why not but that is for more intelligent people than little old me.

Of the 680 patients originally enrolled 39 were lost to follow up leaving the breakdown of patients as:

  • n=286 exergaming 2x [EX2 Group]
  • n=272 exergaming 1x [EX1 Group]
  • n=83 control [CON Group]

The exer-gaming itself consisted of using 3 modules from the Xbox 360: Reflex Ridge, Space Pop and Just Dance. Reflex Ridge prompts users to reflexively respond to visual stimuli; Space Pop prompts users to reach targets to improve spatial orientation and Just Dance prompts users to generate and combine movement sequences as illustrated by video clips. The idea behind the three exer-games chosen was a combination of attention, executive function and the high speed of cognitive processing required for oncoming visual and auditory cues.

The research really needs to be read in its entirety to do justice to the breadth and depth of the results but suffice it to say that the data suggests that high intensity exercise therapy (especially with an exer-gaming element) is effective for improving ADL independence in subacute persons with stroke and that improvements can be especially sizeable if therapy is administered twice daily.

To pick just one measure patients in the EX2 group walked approximately 125 metres further than at baseline which was nearly twice the gain of the lower frequency EX1 and CON groups. It should be noted that these patients were 3 weeks post stroke when therapy began.

Prior to commencing the study researchers had conceptualised that most patients with stroke respond well to exercise stimuli and that the ensuing adaptations induce brain plasticity in a dose dependent manner.

Conventional wisdom has been that patients need to rest between therapy sessions in order for neuroplasticity to emerge but patients in the EX2 group exercised between 08:00 - 09:00 and 14:00 - 15:00 daily and researchers observed no signs that high intensity frequency interfered with either clinical or motor adaptations: in fact it seemed to promote them.

There was also a secondary effect which I will term a ‘confidence’ factor in that patients in the EX2 group had a high self-perception of their ability to perform ADL’s.

All, I’m sure you will agree, interesting stuff as we move into an age where the delivery of remote therapy and virtual rehab become more and more prevalent.

If you need any further information about this topic, please contact Ian Slater.

Further Reading