View of Effects of Game-Based Task-Oriented Circuit Training on Physical Functions of Stroke Survivors: A Pilot Study in A State Hospital in Kelantan, Malaysia

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AJMB, Official Journal of Faculty of Medicine, Universiti Sultan Zainal Abidin, Malaysia. Mohd Naqiuddin et al.

Effects of Game-Based Task-Oriented Circuit Training on Physical Functions of Stroke Survivors: A Pilot Study in A State Hospital in Kelantan, Malaysia

Mohd Naqiuddin Johar^1,2*, Nor Azlin Mohd Nordin², Yusliza Azreen Mohd Yusoff³

1Physiotherapy Unit, Hospital Raja Perempuan Zainab II, 15586 Kota Bharu, Kelantan

2Physiotherapy Programme, Center for Rehabilitation and Special Needs Studies, Faculty of Health Sciences,

Universiti Kebangsaan Malaysia,

3Medical Department, Hospital Raja Perempuan Zainab II, 15586 Kota Bharu, Kelantan

*[email protected]

Abstract

Despite being increasingly popular and commonly used in rehabilitation, both game-based exercise training and task-oriented circuit training have never been combined to provide a new training experience for stroke survivors undergoing rehabilitation.

Past studies have assessed the effectiveness of these exercise approaches separately and reported positive outcomes.

Combining the two training programs may create a more enriched environment and yield favorable outcomes. The aim of this study was to determine the effects of game-based task-oriented circuit training on the physical functions of stroke survivors.

This research was a pretest-posttest experimental pilot trial involving 30 participants at post-acute and chronic stage post- stroke (mean age and standard deviation = 58.9 ± 6.6 years; mean Montreal Cognitive Assessment scoring = 23.4 ± 7.1) conducted at a state hospital in Kelantan, Malaysia between August 2019 to February 2020. All participants received game- based task-oriented circuit training using a “Checkercise Board” for 45 minutes, twice per week for 8 weeks. The outcome of the training was measured with regard to lower limb strength, functional stability and aerobic capacity, with the use of the 30- second chair rise test, Dynamic Gait Index (DGI) and 6-minute walk test, respectively. Analysis was done by the ‘intention- to-treat’ approach, using paired samples t-test to determine the differences between pre and post-training outcomes scores. All data was analyzed using the Statistics Package for the Social Sciences (SPSS), version 23.0. The significance level was set at p < 0.05 and Cohen’s (d) was used to determine the effect size. Post-training, participants’ mean 30-second chair rise test, DGI and 6-minute walk test scores increased by 9%, 7% and 23% respectively compared to pre-treatment (p < 0.05), with medium effect size of 0.5 to 0.6. Game-based task-oriented circuit training effectively improves lower limb strength, functional stability and aerobic capacity of stroke survivors, and may be used as a therapy option for this population. A future study is needed to confirm these study findings.

Keywords: Game-based therapy, task-oriented circuit training, physical function

*Author for Correspondence

Cite as: Mohd Naqiuddin, J., Nor Azlin, M. N., Yusliza Azreen, M. Y. (2021). Effects of Game-Based Task- Oriented Circuit Training on Physical Functions of Stroke Survivors: A Pilot Study in A State Hospital in Kelantan, Malaysia, Asian Journal of Medicine and Biomedicine, 5(S2), 5–14, https://doi.org/10.37231/ajmb.2021.5.S2.454

DOI: https://doi.org/10.37231/ajmb.2021.5.S2.454

Asian Journal of Medicine and Biomedicine, Vol 5:S2.

Original Article Open Access

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Introduction

Stroke is a major cause of death and disability in many countries. It was reported that, in 2013, globally, there were nearly 25.7 million stroke survivors, 6.5 million deaths due to stroke and 10.3 million new cases of strokes ^[1]. The prevalence of stroke in several Asian countries, including Malaysia, was estimated to be between 7.2% and 9.4%, most of them living with some forms of disability ^[2-4].

Despite the advancement in stroke management, the global burden of the disease remains high. A total of 113 million disability-adjusted life-years (DALYs) were reported because of strokes globally in 2013 ^[1]. In Malaysia, the burden of stroke is also high, reported as 337, 935 DALYs (41.2%) in 2016 and this figure will continue to increase in the coming years ^[5]. Due to this, the number of patients who will need neurological care is projected to increase in the near future.

A stroke can have a devastating impact on an individual’s life, both physically and emotionally. Clinically, the physical impact most often manifests as weakness, with other common dysfunctions such as functional instability, sensory impairment and low aerobic endurance ^[6]. Consequently, stroke survivors have a relatively poor quality of life pertaining to the physical function components. Thus, rehabilitation is increasingly important to enable stroke survivors to return to their pre-morbid life.

After a stroke, the improvement of physical function is an important objective for physiotherapy, which has a range of treatment modalities such as therapeutic exercises, water- based exercises, electro-stimulation therapy, virtual reality and specific skills approaches such as Neurodevelopmental Therapy/Bobath, Brunnstrom and proprioceptive neuromuscular facilitation as recommended by numerous guidelines ^[6-9]. Improvements following therapy are commonly measured in terms of change in the strength of the affected limbs, functional stability or dynamic balance, walking ability and aerobic capacity, to name some examples ^[10-14].

Physiotherapy has been shown to be well accepted by stroke survivors as an important intervention post-stroke. However, compliance or adherence to therapy remains an issue that threatens the success of physiotherapy. There is a growing need for more interesting and motivating therapy approaches to address this issue and improve treatment adherence. One such approach is game-based exercise training, which can turn rehabilitation into a more appealing session and provide personalized motivation for stroke patients with various needs. This approach has been reported to contribute towards better functional recovery after stroke compared to usual physiotherapy ^[15-18]. Past researchers detected significantly greater improvements in functional stability, measured using timed-up and go test following game-based training between 4 to 10-week. Another approach which is

considered motivating is circuit exercise training. Circuit exercise training, which normally focuses on training of task-oriented activities, has received much attention in past research and good evidence has been documented ^[19]. However, with both approaches, adherence is still an issue to be addressed. To date, despite being increasingly used in physiotherapy, both game-based exercise training and task- oriented circuit training have never been combined to provide new training experience for stroke survivors undergoing rehabilitation. Combining the two training programs may create a more enriched environment and yield favorable outcomes. Therefore, this study aimed to merge the two trainings and evaluate the effectiveness of game- based, task-oriented circuit training on the physical functions of stroke survivors, namely lower limb strength, functional stability and aerobic capacity, which are three important post-stroke outcomes.

Methods

Study design and location

This is a one group pretest-posttest pilot experimental study which was conducted at the physiotherapy department of a state hospital in Kelantan, Malaysia. The study was approved by the National Medical Research Review, Kementerian Kesihatan Malaysia (study code NMRR-19- 2961-51209-IIR).

Participants

Thirty clinically diagnosed stroke patients aged between 55 to 75 years, with a post-stroke duration of 2 months or more were recruited in this trial. The inclusion criteria were 1) able to walk continuously for 10 meters independently with or without walking aid, 2) able to perform basic instrumental activities of daily living such as walking, stepping up and turning with or without walking aid, 3) able to hold a glass full of water in the non-affected hand, 4) able to follow 3 step commands, and 5) physically healthy without significant disability based on Nagi’s concepts ^[20]. Stroke survivors who have 1) more than one episode of stroke, 2) other neurological disorders such as Parkinson’s Disease and traumatic brain injury, 3) an average Montreal Cognitive Assessment (MoCA) score of 22.1 and less, 4) orthopedic conditions resulting in joint deformities such as, severe osteoarthritis or rheumatoid arthritis, and 5) visual field defects were excluded from the trial.

The sample size for the study was calculated using G*Power 3.1.9.2 software. Selecting paired samples t-test as the intended test, study power of 80% or 0.8, and estimating large effect size (Cohen f=0.4), the yielded minimum number of participants required for this study was 30 participants. Drop-outs were not considered in the sample size estimation because an intention to treat analysis was intended, in which all participants recruited at baseline would be analysed at the completion of the trial.

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Intervention

All participants performed a game-based task-oriented circuit training using a newly designed exercise board known as Checkercise (Figure 1).

Figure 1 Some examples of exercise included in Checkercise board

The design of the Checkercise is similar to the ‘snake and ladder’ game board. A total of 30 exercises were included in the Checkercise training board, which consisted of resistance exercises, balance exercises and aerobic exercises as shown in Table 1. The exercises were prescribed based on the ‘frequency, intensity, time and technique’ (FITT) principle, which differed in the level of difficulty. To use the Checkercise board, the participants were first required to place their counter on the space that indicated 'start'. Then, they had to take a turn to rolling a dice. Next, they had to move their counter forward by several spaces based on the number as shown on the rolled dice. Exercises to be performed by the participants would depend on where their counter landed on the board each time the dice was rolled, as each space shows a different exercise task. There was also a possibility of being penalised during the training if their counter landed on ‘penalty spaces’, such as spaces which indicate ‘slide back a few spaces, and ‘move to a certain board number’. The game-based circuit exercises were considered completed when participants arrived at a space that indicated 'finish'.

All participants performed the exercises at a metronome pace, and the pattern, intensity and physiological demand of each exercise were matched between each participant to ensure similarity. All selected exercises focused on advanced and challenging task-oriented training to trigger autonomic responses, divided attention and multi-tasking ability among the stroke patients. To minimize risks of over exertion, all participants were monitored in terms of individuals’ rate of perceived exertion using a Borg Scale.

Overall, this therapy program was implemented for 45

minutes in each session, twice per week for an 8-week period.

Measurement of intervention outcomes

The intervention (training) outcomes were evaluated at the end of week eight by an independent assessor. Three standardized outcome measures were used, namely 30- second chair rise test, Dynamic Gait Index (DGI) and the 6- minute walk test to assess lower limb muscle strength, functional stability, and aerobic capacity, respectively ^[21-23]. All outcome measurements have been validated (r=0.66- 0.99) with high reliability (intra-class correlation coefficient=0.89-0.99) to obtain a reasonable measure of physical functions among the stroke population.

30-second chair rise test

Participants were instructed to sit and stand repetitively as quickly as possible for 30 seconds on a 42 centimeters high and 47.5 centimeters deep chair while their arms were crossed at the wrist and held against the chest. The number of complete sits to stand tasks performed in 30 seconds was recorded.

Dynamic Gait Index

Participants were instructed to perform all 8 tasks, which consisted of:1) walking on level surface, 2) walking while changing speed, 3) walking while turning head horizontally, 4) walking while turning head vertically, 5) walking with pivot turn, 6) stepping over obstacles, 7) stepping around obstacles, and 8) stair climbing. Each task is scored using a 4-point ordinal scale ranging from 0 (severe impairment) to 3 (normal). The total score ranges from 0 to 24 and a higher total DGI score signifies a higher level of functional mobility independence among stroke survivors.

6-minute walk test

Participants were instructed to walk at a comfortable pace along a marked walking course of 10 meters in length. The total distance walked in 6 minutes was recorded in meters.

Statistical analysis

All data was analyzed using the Statistics Package for Social Sciences (SPSS), version 25.0. A paired samples t-test was used to analyze the mean differences in each outcome score of the participants following the 8-week intervention. The level of significance was set at p < 0.05 and Cohen’s (d) was used to determine the effect size of either small (0.2), moderate (0.5) or large (0.8).

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Results

Participant flow in each study phase

During the trial, three participants dropped out of the intervention due to logistical issue. The three participants were included in the final analysis based on intention-to- treat analysis i.e., their baseline scores were carried forward as outcome scores (Figure 2).

Baseline characteristics

The baseline characteristics of the 30 participants are shown in Table 2. All participants were either at post-acute or chronic stage post-stroke onset and their mean age + standard deviation (SD) 58.9 ± 6.6 years.

Changes in 30-second chair rise test, Dynamic Gait Index and 6-minute walk test following intervention

Participants demonstrated statistically significant (p < 0.05) improvement in all outcomes; 9%, 7% and 23% in the 30- second chair rise test, DGI and 6-minute walk test, respectively. This was based on mean changes of 1.1 frequency, 1.5 points and 58.2 meters, respectively, with a medium effect size between 0.5 to 0.6 in all measurements (Table 3).

Discussion

The purpose of this study was to evaluate changes in lower limb strength, functional stability and aerobic capacity among stroke survivors following a game-based circuit training using a Checkercise board. Due to the inavailability of similar combined training interventions in previous studies, we are unable to compare our results directly with past research. However, we will discuss our findings with reference to studies with similar training components.

Our results found that participants exhibited better lower limb strength as measured using a 30-second chair rise test following the 8-week interventions. In this sense, corroborating our findings, Olafsdottir and colleagues ^[24]

described results after a game-based training using ActivABLES, a human-centered prototype designed for 10 community-dwelling stroke survivors for a 4-week period.

They detected significantly greater improvements in lower limb muscle strength, measured using five times sit to stand test. Another randomized controlled trial in Brazil, presented by Eichinger and colleagues ^[16] addressed the effect of 10- week serious games on 24 subacute and chronic stroke survivors compared to conventional physiotherapy. They reported that serious games promoted improvement in lower limb muscular strength, which was observed in terms of dynamometer.

We hypothesized that the improvement in 30-second chair rise test scores among all participants was achieved through repetitive squatting and sit to stand tasks, which are known to be useful in increasing muscle strength in the lower limbs

[25-26]. In addition, the demand for closed kinetic chain training during most of the exercises on the Checkercise board has increased the lower limb strength, especially the knee musculature ^[27].

We also noted improvement in the functional stability of the stroke survivors, as indicated by an overall increase in DGI score following our game-based circuit exercise training.

This finding is consistent with the results of 36 chronic stroke survivors in an earlier study by Choi and co- researchers ^[15] following either game-based constraint- induced movement therapy or conventional physiotherapy for 4 weeks. The outcome measures used in the study were the Time-Up and Go (TUG) and the functional reach test.

Our study also supports the findings of another study ^[17]

which demonstrated positive improvement in balance ability among stroke survivors, assessed using the TUG test and postural sway using the Wii balance board. They pointed out that a 30-minute 3-session per week game-based training using virtual reality canoes for 5 weeks was more beneficial than conventional therapeutic approaches in improving balance among 30 sub-acute stroke survivors.

We believe that the improvement in DGI score among the stroke participants in our study was obtained through the challenge imposed on the balance control system and the multidirectional automatic response during the exercises using our Checkercise board. These were induced during certain exercise tasks when participants were required to independently shift their bodies and displace their center of gravity beyond the available base of support without losing their balance or stepping aside ^[28]. In the present study, we have selected task-oriented exercises that stimulate lateral weight shift and multidirectional balance maneuvers in standing position. In addition, the nature of each exercise task in the Checkercise training environment is repetitive, dynamic and of moderate intensity; this has stimulated complex motor skills, agility, and automatic responses ^[29]. As for aerobic capacity, we found significant improvement among the stroke participants following the 8-week intervention, measured using 6-minute walk test. These results agree with an earlier study on the effects of game- based training using robot suite rehabilitation devices named Robot Gym on the aerobic capacity of 10 chronic stroke survivors ^[18].

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Table 1 Description of game-based circuit training using a Checkercise board

Formula Resistance exercise Balance exercise Aerobic exercise

Repeated sit to stand Walking on balance beam Alternate jab

Frequency 2 sessions/week 2 sessions/week 2 sessions/week

Intensity Speed at 50 beats per minute Speed at 30 beats per minute Speed at 100 beats per minute

Time 1 minute 1 minute 1 minute

Technique Alternate sitting and standing (without load)

Walking on a balance beam (follow a rhythm)

Repeated jab punching (follow a rhythm) Progression Alternate sitting and standing

(Lifting 2 kg of dumbbell)

Tandem walking (follow a rhythm)

Repeated double jab punching with defense (follow a rhythm)

Repeated partial squat Figure of 8 walking Alternate hook

Technique Standing, partial squats with arm support as needed (without load)

Figure of 8 walking (follow a rhythm)

Repeated hook punching (follow a rhythm) Progression Standing, partial squats with arm support as needed

(Lifting 2 kg of dumbbell/speed at 50 beats per minute)

Figure of 8 walking while holding a cup of water Repeated alternate hook with kicking (follow a rhythm)

Repeated step up & down Walking with instruction Double jab & hook

Intensity Speed at 70 beats per minute - Speed at 100 beats per minute

Technique Standing, alternate step-ups on an 8-inches step board (without load)

Walking & stopping

(closed eyes in static standing)

Repeated double jab punching with hook (follow a rhythm)

Progression Standing, alternate step-ups on an 8-inches step board (Lifting 2 kg of dumbbell/speed at 75 beats per minute)

Walking while responding to a sudden change in instructions Repeated double jab punching with hook & squat (follow a rhythm)

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Continue Table 1

Formula Resistance exercise Balance exercise Aerobic exercise

Standing; repeated hip raise Walk & touch cones Double jab

Technique Standing, alternate step-ups on an 8-inches step board (without load)

Walk & touch cones

(cuboid shape, follow a rhythm)

Repeated double jab punching with defense & kick (follow a rhythm)

Progression Standing, alternate step-ups on an 8-inches step board (Lifting 2 kg of dumbbell/speed at 50 beats per minute)

Walk & touch cones

(hexagon shape, follow a rhythm)

Repeated double jab punching with squat (follow a rhythm)

Standing; repeated heel raise Backward walking Cross straight

Technique Standing, alternate heel raise (without load)

Backward walking (follow a rhythm)

Repeated cross straight punching (follow a rhythm)

Progression Standing, alternate heel raise

(Lifting 2 kg of dumbbell/speed at 75 beats per minute)

Backward walking

(follow a rhythm for 2 minutes)

Repeated 4 times cross straight punching with squat (follow a rhythm)

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Table 2 Baseline characteristics of the stroke participants (n=30)

Variables (mean ± SD) or %

Age (years) 58.9 ± 6.6

Montreal Cognitive Assessment score 23.4 ± 7.1

Body mass index (kg/m²) 26.3 ± 4.3

Ischemic stroke 50

Post-stroke time (months) 3.3

Left/right hemiparesis 78.6/21.4

Left/right hand dominance 14.3/85.7

SD-Standard Deviation

Table 3 Changes in all post-intervention outcomes

Outcome (mean + SD) mean change p value (d)

Before After

30-second Chair Rise test (frequency) 12.5 ± 2.5 13.6 ± 2.6 1.1 ± 1.0 *<0.05 (^#0.5)

Dynamic Gait Index 20.6 ± 3.8 22.1 ± 3.7 1.5 ± 1.7 *<0.05 (^#0.5)

6-minute walk test (meter) 295.7 ± 100.5 353.9 ± 99.3 58.2 ± 95.4 *<0.05 (^#0.6)

SD-Standard Deviation; d-Cohen’s d

* significant, p < 0.05, ^#large effect size, Cohen’s d > 0.8

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Figure 2 Diagram showing the participant flow in each study phase

In the study, participants who completed the 8-week intervention presented a statistically significant improvement in their post-intervention 6-minute walk test performance. De Melo and co-researchers ^[30] likewise reported improvement in walking distance of 37 Parkinson patients measured using 6-minute walk test after gait training using virtual reality 3 times weekly for 4 weeks.

Improvement in 6-minute walk test score among all participants in our study can be associated with the effects of boxing maneuvers in several exercise tasks, which induced greater heart rate throughout the training session.

The punching speed during the boxing maneuver has been prescribed at a medium tempo to induce sufficient metabolic and cardiovascular responses which have been proven to be associated with increased heart rate and ventilation response ^[31]. It has also been proven that boxing manouvers using virtual reality enhanced energy expenditure and oxygen uptake among stroke survivors ^[32-

33] which is comparable to aerobic exercise at moderate intensity ^[34].

Apart from the nature of the circuit exercises included in our Checkercise board, we trust that the element of fun and competition which is induced by the game-based component of our training has enhanced the magnitude of producing a positive influence. Within this enriched

environment, participants worked harder to achieve their best level of functional improvement as neuroplasticity was optimized ^[35-36]. In a relaxing environment, participants’ efforts were further strengthened through a sense of accomplishment or a loss, and through instant feedback received from the therapists throughout the games.

Our study is subjected to several limitations. The small size of study samples and the absence of a control group limit the generalizability of our study results. Due to this, our findings have to be interpreted with caution.

Conclusion

We demonstrated that game-based task-oriented circuit exercise training, using a Checkercise board, is beneficial in improving the engagement of stroke survivors in an exercise training program. The game-based circuit training induced meaningful improvement in physical functions of our stroke survivors, namely lower limb strength, functional stability and aerobic capacity. Future studies with larger samples are recommended to confirm these study findings.

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Acknowledgments

We thanked all participants who have voluntarily involved in this study, and National Medical Research Review, Kementerian Kesihatan Malaysia for the study approval.

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