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Preeti Raghavan, MBBS, and John W. Krakauer, MD, MA, for their contributions as scientific advisors and for critical review of the study proposal. We acknowledge the Sheikh Khalifa Stroke Institute for its support of these projects.

All study procedures are approved by the hospital&#39;s Institutional Review Board. The study obtained informed consent from all participants directly or a legally authorized representative of the patients. 
NOTE: Ultimately, patients will be identified and placed in gaming environments that target their level of impairment. Patients with more impairment&#160;will need gaming systems that support the limb and can be used if the patient has little to no active range of motion. Patients with less impairment and&#160;more active range of motion will require gaming environments that challenge movement against gravity. Prior to identifying the patient and stratifying the patient to a gaming environment, the games must be thoughtfully selected. One-to-one supervision from a trained clinician is recommended to deliver safe and effective treatment to monitor progression and movement quality.
1. Evaluating and selecting the video gaming technology for gameplay
NOTE: This section is meant to be a general guide to help critically think about a technology&#39;s software and game mechanics to identify the best fit for the patients .
<ol>
	<li>Consider the technology&#39;s ability to target the upper limb with attention to the motor, sensory (vision, perception, sensation), and cognitive demands of the game itself and the hardware it interfaces with (controllers, screen, arm support, etc.). See Figure 3 for the technology evaluation criteria. 
	NOTE: This section also describes other considerations, including ease of use for the participant and practitioner. See Figure 4 for a description of the domains and considerations when deploying gaming technology in a clinical setting.</li>
	<li>Consider time in the game, degree of difficulty in the game, and the position of the patient during gameplay as ways to adjust difficulty to challenge the patient and progress the patient as they recover.</li>
</ol>
<img alt="Figure 3" class="xfigimg" src="/files/ftp_upload/68586/68586fig3.jpg" /> 
Figure 3: Technology evaluation criteria. <a href="https://www.jove.com/files/ftp_upload/68586/68586fig3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
<img alt="Figure 4" class="xfigimg" src="/files/ftp_upload/68586/68586fig4.jpg" /> 
Figure 4: Implementation criteria. Designing a behavioral intervention to promote early stroke recovery in hospitalized patients: Domains and Considerations. <a href="https://www.jove.com/files/ftp_upload/68586/68586fig4large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
2. Identifying the patient
<ol>
	<li>Screen patients admitted to the hospital in the acute stroke unit or inpatient rehabilitation facility with a diagnosis of stroke for participation.</li>
	<li>Set the inclusion criteria as follows: Age greater than 18 years, diagnosis of stroke with&#160;onset between 2-14 days of enrollment, ability to follow 1-step commands, and measurable arm weakness caused by stroke.</li>
	<li>Set the exclusion criteria as follows: Upper limb orthopedic injuries, co-morbid neurologic diagnosis other than stroke, or vision impairment that impede the ability to participate in gaming activities (See Table 1).</li>
	<li>Review the medical chart to ensure positional and activity precautions or restrictions are not present.</li>
	<li>Obtain informed consent from all participants directly or approach a legally authorized representative to consent for patients unable to provide consent for themselves, with assent obtained from those individual patients.</li>
	<li>Complete baseline assessments (including grip strength and Fugl Meyer Upper Extremity-FMUE)29,30,31,32,33.</li>
</ol>
<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>Inclusion</td>
			<td>Exclusion</td>
		</tr>
		<tr>
			<td>Adults &#62; 18 years old&#160;</td>
			<td>Current or previous neurologic impairment interfering with ability to complete study procedures determined by study team/ PI&#160;</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td></td>
			<td>Pre-morbid or concurrent orthopedic injury of the affected upper extremity&#160;</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Acute ischemic or hemorrhagic stroke within 14 days of stroke onset at the time of enrollment</td>
			<td>Inability to sit upright for at least 30 minutes</td>
		</tr>
		<tr>
			<td></td>
			<td></td>
		</tr>
		<tr>
			<td>Upper extremity weakness as a result of stroke, defined as FMUE Score between 6-58</td>
			<td>Active seizure or history epilepsy</td>
		</tr>
	</tbody>
</table>
Table 1: Inclusion and exclusion criteria.
3. Stratifying the patient and determining the gameplay approach
NOTE: The remainder of this protocol refers generally to two gaming environments selected using the above criteria for patients with severe-moderate impairment and moderate-mild impairment. The severe-moderate impairment gaming environment provides bilateral limb support with a closed-chain configuration. The moderate-mild impairment gaming environment involves a markerless-sensor-based tracking system that allows for movement in three-dimensional space. Specific commercial device names are intentionally omitted to underscore that the described approach is device-agnostic. The methodology and therapeutic framework presented here are adaptable to any technology platform that satisfies the outlined biomechanical and engagement requirements for the intended patient population.
<ol>
	<li>Determine the treatment goal and appropriate gaming environment based on the FMUE score&#160;(see Figure 1).
	<ol>
		<li>Stratify patients with flaccid hemiparesis or emerging upper limb movement (FMUE score &#60; 25) to the limb-supported gaming protocol (severe-moderate impairment level).</li>
		<li>Stratify patients with proximal movement against gravity and FMUE &#62; 46 to the gaming protocol that requires movement in 3-dimensional space (moderate-mild impairment level).</li>
		<li>Determine an appropriate gaming environment for patients with a mid-range FMUE score or varied proximal or distal strength against gravity (FMUE score of 26&#8211;45) based on patient-specific factors such as cognitive functioning, language impairment, visual impairment, tolerance to usual rehabilitation activities, and degree of proximal shoulder and trunk control. If available, consider body weight assistance to support the limb and ensure movements are out of synergy for patients with proximal weakness.</li>
	</ol>
	</li>
</ol>
4. Deploying the game
<ol>
	<li>Evaluate patient readiness for gameplay.
	<ol>
		<li>Confirm medical stability for that day&#39;s session prior to session start.</li>
		<li>Gather and record baseline physiological parameters, including heart rate (HR), blood pressure (BP), fatigue score (i.e, Visual Analog of Fatigue Scale), and pain score (i.e, Wong-Baker FACES Pain Rating Scale)2,3,34,35.</li>
		<li>Determine gameplay readiness, gameplay position, and gameplay movement strategy (see Figure 2). 
		NOTE: If the session is unable to be initiated on a planned treatment day, record the reason.&#160;</li>
	</ol>
	</li>
	<li>Test the equipment prior to starting the patient session to ensure the necessary hardware and software are connected and ready for use.</li>
	<li>Document session start time and baseline physiological parameters on the designated form.</li>
	<li>Set the patient up in the gaming environment and deploy the game. 
	NOTE: For the patients with severe-moderate impairment, gameplay should include external limb support to protect the shoulder and promote movement outside of abnormal flexor and extensor synergies. At this impairment level, bilateral arm-training environments are recommended, particularly those that use coupled devices in which movement of one limb assists or drives the other. These systems enable an active-passive progression where the less-affected limb initially supports movement of the affected limb and effort gradually transitions to the paretic limb. Coupled systems may support both phasic (mirrored/symmetric) and anti-phasic (alternating/assymetric) movement patterns. These features enable graded progression from assisted movement of the affected limb to independent unilateral control of the paretic limb.&#160; Chedoke Stage of ARM and HAND can be used to determine patient readiness for game progression. The Chedoke McMaster stages of arm recovery is a tool that grades the patient&#39;s level of impairment based on the Brunstromm Stages of Motor Recovery (1 = flaccid, no voluntary movement; 7 = normal movement)20,36. Introduce this measurement tool for software that has joint-specific games. (i.e, games that differentiate between arm movements versus hand movements as a control strategy). Initiate the Chedoke-McMaster assessment to determine the stage of the arm and hand20.
	<ol>
		<li>Position the patient comfortably in a supported seated position in front of the device. Allow for full scapular range of motion.</li>
		<li>Ensure the game integrates both the affected and less-affected side and fit the patient into supportive devices to ensure proper alignment per device instructions.</li>
		<li>Select game settings for the active and passive sequence. 
		NOTE: The patient will complete an active/passive training progression for a target time on task. The therapist will introduce them to active and passive movement in the coupled arm trainer. For the active component, the patient will participate in the game for 1 min with their affected side only. If the game requires two arm participation, then the patient will attempt both arms after the single arm trial and use the less-affected arm to &#34;drive&#34; for 5&#8211;10 min pending the patient&#39;s tolerance. During the passive component, cue the patient to avoid activating their affected side and let their less-affected arm do the work15,17,19.
		<ol>
			<li>For patients with Chedoke stages of ARM 4 and greater, incorporate games that target the elbow and forearm including movements such as elbow flexion and extension and forearm pronation and supination.&#160; 
			NOTE: If patient advances to Chedoke stage of ARM 4-7, consider re-administering the FM-UE and revisiting the stratification model to ensure the most appropriate gaming environment for the participant.</li>
			<li>For patients with Chedoke HAND between 4&#8211;7, incorporate games that target hand movements.&#160;</li>
		</ol>
		</li>
		<li>Begin active-passive sequence. In coupled gaming system, have affected arm attempt active gameplay for 1 min.&#160;</li>
		<li>Transition to the passive part of the sequence. Place both arms in the coupled limb support and use the less-affected limb to move the affected arm in the gaming environment for 5&#8211;10 min.&#160; 
		NOTE: One will play multiple rounds but will complete an active sequence after every 5&#8211;10 min round.</li>
		<li>End active-passive progression when the target TOT is achieved or if the Stopping Criteria (Figure 5) are met.</li>
	</ol>
	</li>
	<li>For patients with moderate-mild impairment, identify a gaming system that requires movement in 3D space.
	<ol>
		<li>Determine patient gameplay position (refer to Figure 3).&#160;
		<ol>
			<li>If playing in a standing position, place a chair behind the patient for safety.</li>
			<li>If playing in a sitting position, ensure seat height to promote hips, knees, and ankles at 90 degrees of flexion.</li>
			<li>Encourage upright positioning with minimal trunk excursion (anterior/posterior and lateral lean) during reach.</li>
			<li>Remind patients to keep their weight equally distributed between their feet and maintain them flat on the floor. 
			NOTE: Always start the first session on the easiest and most introductory levels, and subsequent sessions should begin where the game was left off. As the patients progress through the levels, they may transition from unilateral to bilateral gameplay. During bilateral gameplay, the client will use their less impaired arm to engage added game functions using the game controller.&#160;</li>
		</ol>
		</li>
		<li>Monitor patient response during gameplay and pause the session if there are any changes.</li>
		<li>Refer to the Stopping Criteria to determine if gameplay should be continued or terminated (Figure 5). 
		NOTE: The Stopping Criteria (Figure 5) provides a standard procedure to monitor the participant for tolerance, identify clinical signs that may warrant further action, respond appropriately, and maintain treatment precision in language of varying degrees of intolerance to define the patient response. The algorithm uses a &#34;stoplight&#34; scheme that was adapted from previous work in critically ill populations in which the treating clinician identifies the participant&#39;s clinical signs/ symptoms, which stratifies them into a risk category to guide appropriate action37.</li>
		<li>Record safety events during gameplay: defined as falls, skin breakdown, line dislodgement, vital sign change outside of parameters, or a change in pain that requires stopping.&#160; 
		NOTE: If an event occurs during the session, notify the care provider immediately and terminate the session if the provider deems the patient unsafe to continue.</li>
		<li>End gameplay when the target TOT is achieved or if the Stopping Criteria are met.&#160; 
		NOTE: Therapy is given during weekdays for up to 60 min of TOT training in addition to the standard of care.</li>
	</ol>
	</li>
</ol>
<img alt="Figure 5" class="xfigimg" src="/files/ftp_upload/68586/68586fig5v3.jpg" /> 
Figure 5: Stopping criteria used during video game therapy sessions. <a href="https://www.jove.com/files/ftp_upload/68586/68586fig5v3large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
5. Measuring outcomes
<ol>
	<li>Collect post-intervention outcomes prior to hospital discharge, including FMUE, grip strength using a dynamometer, and qualitative assessment of the patient experience. Add additional measures that are specific to the individual game (i.e., level of difficulty of the game, amount of AI used, distance traveled in the game etc.). 
	NOTE:&#160;For the purpose of gaming studies, the Patient Experience Survey, Intrinsic Motivation Inventory, and Technology Acceptance Model questionnaire38&#160;were used to capture patient experience.</li>
</ol>

No conflicts of interest to report.

Gaming technology to support brain recovery, especially after stroke, is increasingly gaining clinical attention to enhance traditional rehabilitation strategies6,9,10,11. Critical to implementing any technology-based intervention study is the determination of the game potential, and patient selection to assure a clearly defined cohort that are able to benefit from the gaming intervention <sup ...

The prevalence of upper extremity impairment after stroke has been reported between 40-80%1,2. Loss of upper extremity function makes it difficult to coordinate both arms and to complete the most basic of needs3. In the early phases, weakness or paresis can lead to non-use, which can be exacerbated by sensory deficits or pain4. This loss of function greatly impacts the quality of life and access to the environment. Well-defined, evidence-based, effective treatments have yet to be proven for upper limb recovery with a paucity of data in the early post-stroke period5. Timing, dosing, patient selection, and type of intervention are important considerations, with some consensus leaning towards early, intensive, task-specific training as the gold standard6,7.
Immersive video gaming therapy (VGT) can enhance both motivation and high-quality movements of the impaired upper extremities after neurological insult8,9. These technologies integrate components of bilateral training in dynamic gaming environments to promote goal-oriented task completion. Gaming and virtual reality (VR) in the early phase after stroke have shown a positive dose-response relationship, though most of the research specific to the applications of VGT has focused on the subacute period8. New data has emerged about the need for earlier, high-repetition upper extremity interventions, as well as standardization of dose and timing of interventions to facilitate comparative research into the acute stroke period9,10. Recent systematic reviews have shown that daily targeted arm training in addition to standard of care for upwards of 40-60 h within the first 3 months after stroke results in clinically meaningful gains11,12. Based on expertise in the field and the activity tolerance of hospitalized acute and subacute stroke patients, efforts were made to achieve up to 60 min of time on task daily in addition to standard care.
Stroke patients are heterogeneous in many ways, including the amount of pre-stroke activity to which they were accustomed. Establishing a dose goal is a multidimensional proposition for behavioral techniques such as gaming. Dose defining studies must identify the &#34;no-effect&#34; dose, the mean effective dose, and the maximal effective dose while accounting for patient tolerance. As future clinical trials navigate this complex space, we suggest that protocols become standardized to establish a learning period, measure baseline performance, then conduct incremental increases in repetition and Time on Task (TOT). It is important to incorporate minimum standard measures such as TOT and time engaged with the treatment team (noted as total session time), as well as biomarkers of tolerance, including heart rate, hemodynamic determinants, and measures of cardiorespiratory fitness, to understand the feasibility and dose-response relationship of the intervention delivered. In this standardized protocol, the primary measure of dose is direct TOT with the impaired limb for up to 60 min in addition to the standard of care therapy sessions delivered up to 5 days a week13,14.
Thoughtful game selection is crucial for maximizing patient engagement and reducing impairment. As the field evolves it will be critical to adjudicate potential games for safe and meaningful use with acute stroke patients. In the standardized gaming protocol presented here, we identified gaming environments that promote quality of movement relative to the participant&#39;s current capacity. For example, patients with more severe impairment require full limb support and a device that allowed movements in an active and passive progression15,16. This active-passive progression has been shown to improve motor performance when sequenced as active movement of the affected arm followed by passive movement of the affected arm driven by the less-affected arm15,17,18,19. On the other hand, patients with more proximal strength against gravity use a gaming protocol that encourages functional reach in 3-dimensional (3D) space without limb support and forces use of the affected arm while progressively increasing difficulty with the introduction of bilateral gaming in an asymmetric fashion&#160;(Figure 1).
<img alt="Figure 1" class="xfigimg" src="/files/ftp_upload/68586/68586fig1.jpg" /> 
Figure 1: Stratification scheme for selecting video gaming modalities based on the severity of limb weakness. <a href="https://www.jove.com/files/ftp_upload/68586/68586fig1large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
Most gaming modalities have adjustable settings or progressive levels that can be modified to increase or decrease the degree of difficulty for the patient. Protocols should include considerations specific to adjusting gaming dose or intensity as the patient improves and acquires learned skills for gameplay. Titration of gaming difficulty may motivate the patient, maintain engagement, and sustain patient participation. To maximize safety, consistency of gaming deployment, and appropriate challenge to optimize patient recovery, we created an algorithm for patient-level considerations and subsequent targets for gaming progression based on the Chedoke-McMaster Stroke Assessment Impairment Inventory in the domains of shoulder pain, posture control, and arm control20. This algorithm (Figure 2) was grounded in a framework used in a previous study by this research team and adapted for the inpatient population to guide clinicians in appropriate patient positioning and limb support during gameplay13. All treating research clinicians were trained using this algorithm to guide their decisions.
<img alt="Figure 2" class="xfigimg" src="/files/ftp_upload/68586/68586fig2.jpg" /> 
Figure 2: Precision gameplay algorithm. Standardized guidance for player setup and gameplay titration to maximize safety and targeted training. <a href="https://www.jove.com/files/ftp_upload/68586/68586fig2large.jpg" target="_blank">Please click here to view a larger version of this figure.</a>
To accelerate the translation of these technologies to patient care spaces, it is important to have a clear vision of the technology&#39;s attributes to target the specific impairment and the best timing for its use. In addition to thoughtful technology selection, strict protocols that assure safety and adherence must be deployed to maximize the utility of these technologies in the patient care space in a way that demonstrates benefit. Prescribed delivery protocols like the one described in this paper will be essential to answering questions regarding dose, comparing available technologies, and measuring effect in a heterogeneous stroke population. Technology can be safe with the potential to improve outcome but have not been fully tested in the early recovery period during acute hospitalization21. In this paper, we describe a standardized methodology for use in all gaming studies of upper limb recovery in the acute to early subacute post-stroke period22,23,24,25,26,27,28.

<table><tbody><tr><td>Visual Analog of Fatigue Scale</td><td>NA</td><td>NA</td><td></td></tr><tr><td>Wong Baker Pain Rating Scale (with permission from the foundation)</td><td>Wong-Baker Faces Foundation</td><td>&lt;a href=&quot;https://wongbakerfaces.org/research-use/&quot;&gt;https://wongbakerfaces.org/research-use/&lt;/a&gt;</td><td>&lt;a href=&quot;https://wongbakerfaces.org/&quot;&gt;https://wongbakerfaces.org&lt;/a&gt;</td></tr><tr><td>Fugl Meyer-UE</td><td>N/A</td><td>Fugl-Meyer et al., 1975</td><td>https://www.gu.se/en/neuroscience-physiology/fugl-meyer-assessment</td></tr><tr><td>Dynamometer</td><td>Handexer Grip Strength Tester</td><td></td><td></td></tr><tr><td>&amp;nbsp;Technology Acceptance Measure</td><td></td><td></td><td></td></tr><tr><td>Intrinsic Motivation Inventory</td><td></td><td></td><td>&lt;a href=&quot;https://selfdeterminationtheory.org/intrinsic-motivation-inventory/&quot;&gt;https://selfdeterminationtheory.org/intrinsic-motivation-inventory/&lt;/a&gt;</td></tr><tr><td>Chedoke McMaster Stroke Assessment (need formal permission for official use in research or clinical practice)</td><td></td><td></td><td>&lt;a href=&quot;https://www.sralab.org/sites/default/files/2017-07/CMSA%20Manual%20and%20Score%20Form.pdf&quot;&gt;https://www.sralab.org/sites/default/files/2017-07/CMSA%20Manual%20and%20Score%20Form.pdf&lt;/a&gt;</td></tr></tbody></table>

prescribed video game treatment to promote early recovery for hospitalized stroke patients: concepts in standardized implementation

Prescribed Video Game Treatment to Promote Early Recovery for Hospitalized Stroke Patients: Concepts in Standardized Implementation

Patients with stroke often have upper limb impairment that impacts function and quality of life. Increased amounts of arm training in the early phase post stroke may reduce impairment of the arm, but are not achieved in standard therapy. Video Gaming Technology (VGT) has been shown to improve activity, participation, and function, and could be a unique and engaging strategy for training the arm in high doses when delivered during critical periods and within the standard of care. This paper describes a standardized approach to implementing prescribed VGT for patients hospitalized with acute stroke stratified by level of impairment. This is a description of a novel methodology used with adult patients hospitalized with acute stroke and upper extremity impairment in the stroke unit or the acute inpatient rehabilitation facility. The gaming protocol and stratification model utilize strategies for matching patient-specific impairments to an assigned VGT intervention to optimize engagement and accelerate recovery. In addition, a unique &#39;Stopping Criteria&#39; is described that helps clinicians administer safe game play with acute populations at a goal dose of up to 60 min of time on task (TOT) arm movement. Response is measured to track safe completion of the protocol and response to treatment, including outcomes like change in Upper Extremity Fugl-Meyer (FMUE) from baseline to final evaluation. Preliminary results indicate that VGT is feasible and safe in acute stroke patients when adhering to this standardized method.

The current study of technology-supported stroke care using this methodology is ongoing. 6 roll-up patients are used as representative results. All attempted patients in the roll-up period are included here for analysis. Safety events and TOT were tracked in all participating patients. Roll-up patients were enrolled within 9.6 days of stroke onset and were 58.7 years of age. On average, patients in the roll-up period tolerated 47.6 min of time on task using VGT. Using the stopping criteria, all attempted sessions were co...

Here, we present a standardized approach to implementing prescribed Video Gaming Technology (VGT) for patients hospitalized with acute stroke stratified by level of impairment.

Patients with stroke often have upper limb impairment that impacts function and quality of life. Increased amounts of arm training in the early phase post ...

Our research focuses on how to bring prescribed video gaming into the hospital setting during stroke recovery to help achieve a better quality of life. Evidence increasingly supports that initiated upper limb training in the acute and subacute period can yield greater improvements in function compared to delayed intervention. To begin, evaluate the video gaming technology for its ability to target upper-limb motor and cognitive demands.Screen hospitalized stroke patients for eligibility using the defined inclusion and exclusion criteria. Then review gameplay duration, difficulty level, and patient-positioning to determine whether the technology can be safely adapted for clinical use. Gather and record the patient's baseline physiological parameters, including heart rate, blood pressure, fatigue score, and pain score.Determine gameplay readiness, gameplay position, and gameplay movement strategy. Test the equipment before the patient session to ensure all required hardware and software are properly connected and functional. Record the session's start time and baseline physiological parameters on the designated documentation form.Then position the patient in the gaming environment an

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Johns Hopkins Hospital.  Here, we present a standardized approach to implementing prescribed Video Gaming Technology (VGT) for patients hospitalized with acute stroke stratified by level of impairment.

Prescribed Video Game Treatment to Promote Early Recovery for Hospitalized Stroke Patients: Concepts in Standardized Implementation

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