The relationship between healthcare satisfaction after miscarriage and perinatal grief symptoms: A cross-sectional study on Portugal residents.

OBJECTIVE: 15-20% of identified pregnancies result in miscarriage, which may lead to persistent symptoms of psychological morbidities in some women. Healthcare satisfaction is among the factors believed to influence such negative psychological responses. Here, we present the results of a study conducted in Portugal that analyzes the relationship between healthcare satisfaction, information and support provision and perinatal grief symptoms. METHODS: In a cross-sectional study, symptoms of perinatal grief, degree of satisfaction with healthcare received, and information and support provision data were collected through an online survey aimed at women in Portugal who suffered a miscarriage. 873 were considered eligible. Correlations were performed between perinatal grief scores and healthcare satisfaction rates. Finally, the proportions of information and support received were compared after distributing the sample in groups according to their perinatal grief levels. RESULTS: Healthcare satisfaction correlated significantly with perinatal grief scores, the latter increasing as satisfaction levels decreased. 61.1% of our sample received information about the physical consequences of miscarriage and showed a significantly lower rate of above-threshold perinatal grief symptoms in this group. 18.2% received information about its mental health consequences, with no significant differences in above-threshold symptom rates. 11.7% were offered or recommended mental health support, but no significant differences in above-threshold symptom rates were found. CONCLUSION: Healthcare satisfaction and information on after-miscarriage physical changes correlated significantly with reduced perinatal grief rates after miscarriage. However, any effects of mental health information and psychological support provision need further studies. Training for healthcare providers dealing with pregnancy loss, implementing national guidelines that include follow-up on the parents' physical and psychological health, and including a specialized area in medical structures are advised.

The psychological impact of Early Pregnancy Loss in Portugal: incidence and the effect on psychological morbidity.

Introduction: Worldwide, up to a quarter of all recognized pregnancies result in Early Pregnancy Loss (EPL), also known as miscarriage. For many women, this is a traumatic experience that leads to persistent negative mental health responses. The most common morbidity reported in studies from different countries is complicated grief, usually comorbid with depression, anxiety, and Post-Traumatic Stress Disorder (PTSD). To our best knowledge, no studies characterizing the psychological impact of EPL have been made in Portugal. Methods: An online survey was conducted to evaluate clinical symptoms of perinatal grief, anxiety, depression, and PTSD in women who suffered a spontaneous loss within 20 weeks of gestation. Out of 1,015 women who answered this survey, 873 were considered eligible, and subsequently distributed in 7 groups according to the time passed between their loss and their participation in the study. Results: The proportion of women showing symptoms of all comorbidities was greater in those whose loss had happened within a month, and there was a significant gradual decrease over time in scores and proportions of clinical perinatal grief and PTSD. In terms of depression symptoms, scores dropped significantly in the group whose loss occurred 13-24 months before their participation but proportions oscillated without great changes in the other groups. Regarding anxiety, there were small oscillations, but there was no significant decrease of symptoms over time. Discussion: Overall, despite a general drop in scores for most morbidities over time, substantial proportions of women showed persistent symptoms of clinical morbidities 3 years or more after the loss. Therefore, it is essential to promote monitoring of possible complicated responses to the event, to provide appropriate and timely intervention to those women in need.

The impact of exergames on the functional balance of a teenager with cerebral palsy - a case report.

PURPOSE: To understand the impact of an intensive rehabilitation program based on exergames in balance and lower limb function in a teenager with cerebral palsy. METHODS: The rehabilitation program comprised different customised exergames and was delivered in 5 weekly sessions of 30 min for 4 weeks. Pre-, post-, and 1-month Follow-up assessments included the following metrics: Berg Balance Scale (BBS), Dynamic Gait Index (DGI), Gross Motor Function Measure (GMFM), Posturography, and Gait analysis. RESULTS: We observed increased scores after the intervention of 9/72 points in GMF - Module E (Walk, Run and Jump) and of 9/56 points in BBS, sustained at Follow-up. Changes in function, specifically in the quality and independence of the performance of specific movements such as turning 360°, increased distance reaching forward, walk behind, step over obstacles, and step stairs up and down were also observed. Gait kinematics and Spatio-temporal parameters tended to get closer to the 50th percentile. CONCLUSIONS: We observed positive changes in motor function of a teenager with cerebral palsy, with sustained increased scores at a 1-month Follow-up. Findings are suggestive that intensive rehabilitation programs using exergames with high customisation features are a potentially valuable rehabilitation tool for training balance in teenagers with Cerebral Palsy.Implications for rehabilitationExergames may be a useful for providing balance training for teenagers who have a mixed form of cerebral palsy.Exergames that require body displacement may be suitable for modulating gait kinematics and spatio-temporal parameters.The customisation of virtual rehabilitation tools seems to impact the motivation and effort of the user positively.

The Benefits of Custom Exergames for Fitness, Balance, and Health-Related Quality of Life: A Randomized Controlled Trial with Community-Dwelling Older Adults.

Objective: This research aimed to measure the benefits in older adults' motor performance and quality of life during a 12-week-long multidimensional training combining custom-made exergames and traditional exercise in a complementary manner, compared with traditional training alone. Materials and Methods: Community-dwelling older adults participated in a randomized controlled trial (N = 31) consisting of two weekly exercise sessions of 60 minutes for 12 weeks. Participants allocated to the exergames group (n = 15) had one individual session of exergames and one traditional exercise group session per week. Control group participants (n = 16) had two weekly traditional exercise group sessions. Outcome measures on fitness, balance, and health-related quality of life were measured at the start of the intervention, 6th, 12th, and 16th week (1-month follow-up). Results: The exergames group showed a significant increase in lower-body and upper-body strength from pre- to postintervention. When compared with control, participants had significantly higher developments of upper-body strength from pre- to postassessments. There was a significant decrease in shoulder range of motion between the end of the intervention and follow-up for participants in both conditions. Balance increased significantly during the intervention but decreased at follow-up in both conditions. The mental component of health-related quality of life was significantly higher at the end compared with the start of the intervention in the exergames group, and this difference was significantly higher when compared with control. Conclusion: Integrating personalized exergames designed for multidimensional fitness training in traditional settings can be an effective strategy to enhance older adults' motor performance and mental well-being.

The use of game modes to promote engagement and social involvement in multi-user serious games: a within-person randomized trial with stroke survivors.

BACKGROUND: Serious games are promising for stroke rehabilitation, with studies showing a positive impact on reducing motor and cognitive deficits. However, most of the evidence is in the context of single-user rehabilitation, and little is known concerning the impact in multi-user settings. This study evaluates the impact that different game modes can have on engagement and social involvement during a two-user game. Specifically, we want to understand the benefits of game modalities based on competition, co-activation, and collaboration and analyze the influence of different motor and cognitive deficits and personality traits. METHODS: We developed a two-player setup-using tangible objects and a large screen interactive table-for upper limb rehabilitation purposes. We implemented a game that, while keeping the same basic mechanics, can be played in the three different modes (Competitive, Co-active, and Collaborative). We ran a within-person randomized study with 21 stroke survivors that were paired and played the game in its three versions. We used the Game Experience Questionnaire-Core Module to assess engagement and the Social Presence Module to assess Social Involvement. For personality, motor, and cognitive function, users answered the International Personality Item Pool (short version), Fugl-Meyer Assessment-Upper Extremity, Modified Ashworth Scale, and Montreal Cognitive Assessment, respectively. RESULTS: The Collaborative mode promoted significantly more Behavioral Involvement. The Competitive mode promoted more Flow and Challenge than the Co-active mode with participants with better cognitive performance, with low extraversion, or with higher motor skills. Participants with higher cognitive deficits reported more Competence with the Co-active mode. CONCLUSIONS: Our results indicate that, for multi-user motor rehabilitation settings, the collaborative mode is the more appropriate gaming approach to promote social involvement, showing a high potential for increasing adherence and effectiveness of therapy. Additionally, we show that a player's motor and cognitive ability and personality should be considered when designing personalized tasks for multiplayer settings.

Lessons Learned from Gamifying Functional Fitness Training Through Human-Centered Design Methods in Older Adults.

Background: The design of meaningful and enjoyable Exergames for fitness training in older adults possesses critical challenges in matching user's needs and motivators with game elements. These challenges are often due to the lack of knowledge of seniors' game preferences and technology literacy as well as a poor involvement of the target population in the design process. Objective: This research aims at describing a detailed and scrutinized use case of applying human-centered design methodologies in the gamification of fitness training routines and illustrates how to incorporate seniors' feedback in the game design pipeline. Materials and Methods: We focus on how to use the insights from human-centered inquiries to improve in-game elements, such as mechanics or esthetics, and how to iterate the game design process based on playtesting sessions in the field. Results: We present a set of four Exergames created to train the critical functional fitness areas of older adults. We show how through rapid prototyping methods and multidisciplinary research, Exergames can be rigorously designed and developed to match individual physical capabilities. Moreover, we propose a set of guidelines for the design of context-aware Exergames based on the lessons learned. Conclusion: We highlight the process followed; it depicts 19 weeks of various activities delivering particular and actionable items that can be used as a checklist for future games for health design projects.

Toward Emotionally Adaptive Virtual Reality for Mental Health Applications.

Here, we introduce the design and preliminary validation of a general-purpose architecture for affective-driven procedural content generation in virtual reality (VR) applications in mental health and wellbeing. The architecture supports seven commercial physiological sensing technologies and can be deployed in immersive and non-immersive VR systems. To demonstrate the concept, we developed the "The Emotional Labyrinth," a non-linear scenario in which navigation in a procedurally generated three-dimensional maze is entirely decided by the user, and whose features are dynamically adapted according to a set of emotional states. During navigation, affective states are dynamically represented through pictures, music, and animated visual metaphors chosen to represent and induce affective states. The underlying hypothesis is that exposing users to multimodal representations of their affective states can create a feedback loop that supports emotional self-awareness and fosters more effective emotional regulation strategies. We carried out a first study to, first, assess the effectiveness of the selected metaphors in inducing target emotions, and second, identify relevant psycho-physiological markers of the emotional experience generated by the labyrinth. Results show that the Emotional Labyrinth is overall a pleasant experience in which the proposed procedural content generation can induce distinctive psycho-physiological patterns, generally coherent with the meaning of the metaphors used in the labyrinth design. Furthermore, collected psycho-physiological responses such as electrocardiography, respiration, electrodermal activity, and electromyography are used to generate computational models of users' reported experience. These models enable the future implementation of the closed loop mechanism to adapt the Labyrinth procedurally to the users' affective state.

Combined Cognitive-Motor Rehabilitation in Virtual Reality Improves Motor Outcomes in Chronic Stroke - A Pilot Study.

Stroke is one of the most common causes of acquired disability, leaving numerous adults with cognitive and motor impairments, and affecting patients' capability to live independently. Virtual Reality (VR) based methods for stroke rehabilitation have mainly focused on motor rehabilitation but there is increasing interest toward the integration of cognitive training for providing more effective solutions. Here we investigate the feasibility for stroke recovery of a virtual cognitive-motor task, the Reh@Task, which combines adapted arm reaching, and attention and memory training. 24 participants in the chronic stage of stroke, with cognitive and motor deficits, were allocated to one of two groups (VR, Control). Both groups were enrolled in conventional occupational therapy, which mostly involves motor training. Additionally, the VR group underwent training with the Reh@Task and the control group performed time-matched conventional occupational therapy. Motor and cognitive competences were assessed at baseline, end of treatment (1 month) and at a 1-month follow-up through the Montreal Cognitive Assessment, Single Letter Cancelation, Digit Cancelation, Bells Test, Fugl-Meyer Assessment Test, Chedoke Arm and Hand Activity Inventory, Modified Ashworth Scale, and Barthel Index. Our results show that both groups improved in motor function over time, but the Reh@Task group displayed significantly higher between-group outcomes in the arm subpart of the Fugl-Meyer Assessment Test. Improvements in cognitive function were significant and similar in both groups. Overall, these results are supportive of the viability of VR tools that combine motor and cognitive training, such as the Reh@Task. Trial Registration: This trial was not registered because it is a small clinical study that addresses the feasibility of a prototype device.

The impact of positive, negative and neutral stimuli in a virtual reality cognitive-motor rehabilitation task: a pilot study with stroke patients.

BACKGROUND: Virtual Reality (VR) based methods for stroke rehabilitation have mainly focused on motor rehabilitation, but there is increasing interest in integrating motor and cognitive training to increase similarity to real-world settings. Unfortunately, more research is needed for the definition of which type of content should be used in the design of these tools. One possibility is the use of emotional stimuli, which are known to enhance attentional processes. According to the Socioemotional Selectivity Theory, as people age, the emotional salience arises for positive and neutral, but not for negative stimuli. METHODS: For this study we developed a cognitive-motor VR task involving attention and short-term memory, and we investigated the impact of using emotional images of varying valence. The task consisted of finding a target image, shown for only two seconds, among fourteen neutral distractors, and selecting it through arm movements. After performing the VR task, a recall task took place and the patients had to identify the target images among a valence-matched number of distractors. Ten stroke patients participated in a within-subjects experiment with three conditions based on the valence of the images: positive, negative and neutral. Eye movements were recorded during VR task performance with an eye tracking system. RESULTS: Our results show decreased attention for negative stimuli in the VR task performance when compared to neutral stimuli. The recall task shows significantly more wrongly identified images (false memories) for negative stimuli than for neutral. Regression and correlation analyses with the Montreal Cognitive Assessment and the Geriatric Depression Scale revealed differential effects of cognitive function and depressive symptomatology in the encoding and recall of positive, negative and neutral images. Further, eye movement data shows reduced search patterns for wrongly selected stimuli containing emotional content. CONCLUSIONS: The results of this study suggest that it is feasible to use emotional content in a VR based cognitive-motor task for attention and memory training after stroke. Stroke survivors showed less attention towards negative information, exhibiting reduced visual search patterns and more false memories. We have also shown that the use of emotional stimuli in a VR task can provide additional information regarding patient's mood and cognitive status.

Coaching or gaming? Implications of strategy choice for home based stroke rehabilitation.

BACKGROUND: The enduring aging of the world population and prospective increase of age-related chronic diseases urge the implementation of new models for healthcare delivery. One strategy relies on ICT (Information and Communications Technology) home-based solutions allowing clients to pursue their treatments without institutionalization. Stroke survivors are a particular population that could strongly benefit from such solutions, but is not yet clear what the best approach is for bringing forth an adequate and sustainable usage of home-based rehabilitation systems. Here we explore two possible approaches: coaching and gaming. METHODS: We performed trials with 20 healthy participants and 5 chronic stroke survivors to study and compare execution of an elbow flexion and extension task when performed within a coaching mode that provides encouragement or within a gaming mode. For each mode we analyzed compliance, arm movement kinematics and task scores. In addition, we assessed the usability and acceptance of the proposed modes through a customized self-report questionnaire. RESULTS: In the healthy participants sample, 13/20 preferred the gaming mode and rated it as being significantly more fun (p < .05), but the feedback delivered by the coaching mode was subjectively perceived as being more useful (p < .01). In addition, the activity level (number of repetitions and total movement of the end effector) was significantly higher (p < .001) during coaching. However, the quality of movements was superior in gaming with a trend towards shorter movement duration (p = .074), significantly shorter travel distance (p < .001), higher movement efficiency (p < .001) and higher performance scores (p < .001). Stroke survivors also showed a trend towards higher activity levels in coaching, but with more movement quality during gaming. Finally, both training modes showed overall high acceptance. CONCLUSIONS: Gaming led to higher enjoyment and increased quality in movement execution in healthy participants. However, we observed that game mechanics strongly determined user behavior and limited activity levels. In contrast, coaching generated higher activity levels. Hence, the purpose of treatment and profile of end-users has to be considered when deciding on the most adequate approach for home based stroke rehabilitation.

The combined impact of virtual reality neurorehabilitation and its interfaces on upper extremity functional recovery in patients with chronic stroke.

BACKGROUND AND PURPOSE: Although there is strong evidence on the beneficial effects of virtual reality (VR)-based rehabilitation, it is not yet well understood how the different aspects of these systems affect recovery. Consequently, we do not exactly know what features of VR neurorehabilitation systems are decisive in conveying their beneficial effects. METHODS: To specifically address this issue, we developed 3 different configurations of the same VR-based rehabilitation system, the Rehabilitation Gaming System, using 3 different interface technologies: vision-based tracking, haptics, and a passive exoskeleton. Forty-four patients with chronic stroke were randomly allocated to one of the configurations and used the system for 35 minutes a day for 5 days a week during 4 weeks. RESULTS: Our results revealed significant within-subject improvements at most of the standard clinical evaluation scales for all groups. Specifically we observe that the beneficial effects of VR-based training are modulated by the use/nonuse of compensatory movement strategies and the specific sensorimotor contingencies presented to the user, that is, visual feedback versus combined visual haptic feedback. CONCLUSIONS: Our findings suggest that the beneficial effects of VR-based neurorehabilitation systems such as the Rehabilitation Gaming System for the treatment of chronic stroke depend on the specific interface systems used. These results have strong implications for the design of future VR rehabilitation strategies that aim at maximizing functional outcomes and their retention. Clinical Trial Registration- This trial was not registered because it is a small clinical study that evaluates the feasibility of prototype devices.

Neurorehabilitation using the virtual reality based Rehabilitation Gaming System: methodology, design, psychometrics, usability and validation.

BACKGROUND: Stroke is a frequent cause of adult disability that can lead to enduring impairments. However, given the life-long plasticity of the brain one could assume that recovery could be facilitated by the harnessing of mechanisms underlying neuronal reorganization. Currently it is not clear how this reorganization can be mobilized. Novel technology based neurorehabilitation techniques hold promise to address this issue. Here we describe a Virtual Reality (VR) based system, the Rehabilitation Gaming System (RGS) that is based on a number of hypotheses on the neuronal mechanisms underlying recovery, the structure of training and the role of individualization. We investigate the psychometrics of the RGS in stroke patients and healthy controls. METHODS: We describe the key components of the RGS and the psychometrics of one rehabilitation scenario called Spheroids. We performed trials with 21 acute/subacute stroke patients and 20 healthy controls to study the effect of the training parameters on task performance. This allowed us to develop a Personalized Training Module (PTM) for online adjustment of task difficulty. In addition, we studied task transfer between physical and virtual environments. Finally, we assessed the usability and acceptance of the RGS as a rehabilitation tool. RESULTS: We show that the PTM implemented in RGS allows us to effectively adjust the difficulty and the parameters of the task to the user by capturing specific features of the movements of the arms. The results reported here also show a consistent transfer of movement kinematics between physical and virtual tasks. Moreover, our usability assessment shows that the RGS is highly accepted by stroke patients as a rehabilitation tool. CONCLUSIONS: We introduce a novel VR based paradigm for neurorehabilitation, RGS, which combines specific rehabilitative principles with a psychometric evaluation to provide a personalized and automated training. Our results show that the RGS effectively adjusts to the individual features of the user, allowing for an unsupervised deployment of individualized rehabilitation protocols.

The rehabilitation gaming system: a review.

Stroke will become one of the main burdens of disease and loss of quality of life in the near future. However, we still have not found rehabilitation approaches that can scale up so as to face this challenge. Virtual reality based therapy systems are a great promise for directly addressing this challenge. Here we review different approaches that are based on this technology, their assumptions and clinical impact. We will focus on virtual reality based rehabilitation systems that combine hypotheses on the aftermath of stroke and the neuronal mechanisms of recovery that directly aims at addressing this challenge. In particular we will analyze the, so called, Rehabilitation Gaming System (RGS) that proposes the use of non-invasive multi-modal stimulation to activate intact neuronal systems that provide direct stimulation to motor areas affected by brain lesions. The RGS is designed to engage the patients in task specific training scenarios that adapt to their performance, allowing for an individualized training of graded difficulty and complexity. Although RGS stands for a generic rehabilitative approach it has been specifically tested for the rehabilitation of motor deficits of the upper extremities of stroke patients. In this chapter we review the main foundations and properties of the RGS, and report on the major findings extracted from studies with healthy and stroke subjects. We show that the RGS captures qualitative and quantitative data on motor deficits, and that this is transferred between real and VR tasks. Additionally, we show how the RGS uses the detailed assessment of the kinematics and performance of stroke patients to individualize the treatment. Subsequently, we will discuss how real-time physiology can be used to provide additional measures to assess the task difficulty and subject engagement. Finally, we report on preliminary results of an ongoing longitudinal study on acute stroke patients.