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Table 2 Characteristics of included studies

From: Getting into a “Flow” state: a systematic review of flow experience in neurological diseases

References

Sample characteristics

Population/N

Study Design/N

Intervention

Age (Years) Mean (SD)/Gender

Main outcome parameters

Flow measurement

Key findings regarding flow

Shin et al. (2014) [45]

Acute or subacute and chronic stroke

Prospective Cohort Study (N = 20)

Upper limb training with an interactive game-based virtual reality rehabilitation system RehabMaster™

20 min of RehabMaster™ sessions twice a week for 2 weeks

nr/nr

Upper limb motor function (Fugl-Meyer Assessment (FMA) and modified Barthel Index (MBI)

6 ‘flow’ statements were taken from a 12 item Flow scale

[11]

Flow scores improved between different training sessions using the RehabMaster™

Flow statements

1. attentional focus

2. attentional focus

3. intrinsic interest or pleasure

4. intrinsic interest or pleasure

5. control

6. control

Mean (SD)

0.8 (1.3)

0.6 (1.1)

0.5 (0.8)

4.3 (1.2)

4.1 (1.0)

0.9 (1.0)

p-value

 < .01

 < .01

 < .01

 < .01

 < .01

 < .01

Galna et al. (2014) [43]

Parkinson’s disease (Hoehn & Yahr stage I–III)

Prospective Cohort Study (N = 9)

Dynamic postural control training with exergame Microsoft Xbox Kinect

Duration: 30 min in a Movement Laboratory

68.22

(range 54–78)

6 females

3 males

Semi-structured interview regarding safety and feasibility of the game

Flow State Scale (FSS)

Flow remained at a high-level during gameplay. High scores indicate high level of flow

Subscales

Autotelic experience (AE)

Clear goals (CG)

Challenge-skill balance (CB)

Concentration on Task (CT)

Paradox of Control (PC)

Unambiguous Feedback (UF)

Action Awareness Merging (AM)

Transience of Time (TT)

Loss of self-consciousness (LS)

Mean (SD)

4.03 (0.88)

4.22 (0.88)

3.78 (0.96)

4.56 (0.51)

3.44 (0.98)

3.89 (0.87)

3.11 (1.10)

2.67 (1.14)

4.14 (1.06)

 

van der Kuil et al. (2018) [42]

Acquired brain injury (Cerebrovascular accident (n = 16)

TBI (n = 9)

Brain tumor (n = 4)

Brain hypoxia (n = 1)

Prospective Cohort Study (N = 30)

Cognitive training using computer-based serious Game (game was constructed in the Unity 3D game engine)

Experimental session approximately 60 min of testing

47.2

Range 23 -68

15 females

15 males

Movement control task to assess usability differences between mouse controlled and keyboard controlled

Instruction modality between text-based instructions or video-based instructions

Feedback timing to assess the effect of cumulative versus delayed feedback on performance and motivation

Overall appreciation questionnaire with six items adapted from the Flow State Scale (FSS) and three items constructed in context of the usability test

Flow scores were high as measured on a Likert scale [1,2,3,4,5]

Subscale:

Ease of use

Enjoyment

Clear goals

Rewarding

Control

Attention

Concentration

Willingness to play again

Challenge

Mean (SD)

3.63 (0.25)

4.17 (0.23)

4.00 (0.24)

3.92 (0.22)

3.29 (0.26)

4.79 (0.10)

4.54 (0.19)

4.13 (0.23)

4.08 (0.21)

 

Yoshida et al. (2014) [47]

TBI

(Patient A 948 days since injury; Patient B 228 days since injury)

Exploratory case study (AB-Design)

(N = 2)

Attentional Training with Video game tasks

Patient A: female, 47 years

Patient B: male, 41 years

SDMT, TMT-A and B, RAVLT,

Continuous Performance Test X task (CPT-X)

Moss Attention Rating Scale (MARS)

Flow State Scale for Occupational Tasks (FSSOT)

Flow scores were at high levels and even increased, based on a visual analysis, scores above the mean more than +—SD) after training, and this in both patients

Baker et al. (2015) [52]

Spinal cord injury and acquired brain injury (in-patients)

Non-rando-mized quasi-experi-mental design (N = 10)

Song writing program

Therapists and participant co-created three songs

Duration: 12 sessions (twice weekly,1 h)

Main outcome: self-concept, various well-being Measures

38.90 (13.21)

1 female

9 males

Head Injury Semantic Differential Scale (HISDS) self-concept

Various well-being measures

Flourishing Scale,

Satisfaction with Life Scale (SWLS),

Emotion Regulation Questionnaire (ERQ),

Positive Affect and Negative Affect Scale (PANAS-20),

Patient Health Questionnaire-9 (PHQ-9),

Generalized Anxiety Disorder scale (GAD-7)

Short Flow Scale (SFS)

Core Flow Scale (CFS)

Flow scores were high, mean values > 4 points (measured on a Likert scale of 1–5) for the intervention. The scores did not significantly correlate whether with HISDS nor with well-being measures (Flourishing Scale; SWLS; ERQ; PANAS-20; PHQ-9; GAD-7)

State Flow Scale

correlation state flow with self-concept HISDS

correlation state flow with various well-being measures (Flourishing Scale; SWLS; ERQ; PANAS-20; PHQ-9; GAD-7)

Core Flow Scale

correlation core flow with self-concept HISDS

correlation state flow with various well-being measures (Flourishing Scale; SWLS; ERQ; PANAS-20; PHQ-9; GAD-7)

Mean (SD)

4.02 (0.40)

r = -0.10

r = between -0.40 and 0.43

Mean (SD)

4.14 (0.46)

r = 0.02

r = between -0.24 and 0.32

p-value

p > 0.05

p > 0.05

p > 0.05

p > 0.05

Robinson et al. (2015)

[44]

Multiple sclerosis (not in-patients)

RCT (N = 56)

Balance training with exergame Nintendo Wii FIT™

Randomization in:

Group1: balance training using the Nintendo Wii FIT™ (exergaming) (n = 20)

Group 2: traditional balance training groups (non-exergaming) (n = 18)

Group 3: control group no intervention (n = 18)

Duration: 4 weeks of twice weekly 40–60 min exercise sessions

52.6 (6.1)

14 females

6 males

53.9 (6.5)

12 females

6 males

519 (4.7)

12 females

6 males

Postural sway (using a force plate), gait (GAITRite™), technology acceptance (UTAUT)

Flow State Scale (FSS)

Flow scores on the level of certain subscales were significantly higher in the Wii Fit™ as compared to control group:

Flow Subscale

Autotelic experience

Clear goals

Challenge-skill balance

Concentration on Task

Paradox of Control

Unambiguous Feedback

Action Awareness Merging

Transformation of Time

Loss of self-Consciousness

Wii Fit™

Mean (SD)

4.6 (0.6)

4.3 (0.6)

3.9 (0.5)

4.4 (0.7)

3.8 (0.7)

4.2 (0.7)

3.9 (0.9)

4.1 (0.9)

4.3 (0.7)

Control

Mean (SD)

4.1 (0.8)

4.0 (0.8)

4.2 (0.7)

3.9 (0.8)

3.9 (0.8)

3.9 (1.2)

3.3 (0.7)

2.2 (0.9)

4.3 (0.9)

p-value

0.08

0.05*

0.35

0.03*

0.17

0.04*

0.03*

0.001*

0.23

Yoshida et al. (2018)

[48]

Traumatic Brain Injury at least 6 months post-injury (not in-patients)

RCT (N = 20)

Attentional training with Video game task

Randomization in:

flow group (n = 10) or control group (n = 10)

Patients performed a video game task, one inducing flow (flow group) and the other not (control group) for 4 weeks

41.7 (9.37)

4 females

16 males

SDMT, TMT, PASAT,

Continuous Performance Test X task (CPT-X)

Moss Attention Rating Scale (MARS)

Flow State Scale for Occupational Tasks (FSSOT)

Flow scores were significantly higher in the intervention group than in the control group. Both groups showed a positive, but non-significant correlation between and the FSSOT and composite score of the attention tests (TMT, SDMT, PASAT) (Flow: r = .456, p = 0.21; Control r = 0.554, p = 0.09)

No significant correlation between the FSSOT and the overall MARS score (r = -0.28, p = 0.24). A significant correlation was found between one subscale of MARS (sustained/consistent) and FSSOT (r = -0.51, p < 0.05)

Ku et al. (2018) [46]

Subacute to chronic Stroke

RCT (N = 20)

Hand wrist and foot ankle exercise with Mobile Game play

Randomization in:

Game based-NMES (n = 9) or

Conventional-NMES (n = 11)

20 min per day for 5 consecutive days

Flow measurement during each training session

MG-NMES

63.3 (10.78)

3 females

6 males

C-NMES

5.1 (10.0)

5 females

6 males

No other assessment

modified version of the questionnaire from [11]

6 Flow statements (attention, curiosity and intrinsic interest

As shown, the mean scores of the Flow were > 4 points on a LIKERT scale of 1 to 5, for the MG-NMES so indicating that the patients were at high Flow level during the Mobile-Game play, as this significantly higher as compared to just C-NMES

attention

curiosity

intrinsic interest

MG-NMES

Mean (SD)

4.43 (0.55)

4.11 (0.51)

4.46 (0.42)

C-NMES

Mean (SD)

3.69 (0.73)

3.41 (0.86)

3.86 (0.74)

p-value

0.022*

0.044*

0.031*

Yoshida et al. (2018) [50]

Cerebral vascular disease

Orthopaedic diseases

Neurodegenerative diseases

Spinal cord diseases

Internal diseases

RCT

(N = 56)

Activities of daily living

Randomization in:

Experimental group (n = 28)

OT with evaluating challenge-skill levels by the client and adaption within therapy

Control group (n = 28)

No evaluation of challenge-skill levels by the client

80.9 (8.36)

14 males

81.2 (6.51)

13 males

Health-related quality of life (EuroQol-5 Dimensions)

Short-Form Health Survey for general health (SF-8)

Flow State Scale for Occupational Tasks (FSSOT)

Flow levels were on moderate level (Score ranges 14–98) for both groups. For the experimental group there was a significant difference in flow

FSSOT

Intervention group

Mean (SD)

63.74 (11.56)

Control group

Mean (SD)

54.46 (18.82)

p-value

0.008

Yoshida et al. (2019) [49]

Cerebral, spinal and musculoskeletal diseases

RCT (N = 72)

Activities of daily living

Randomization in:

Experimental group (n = 36)

OT with evaluating challenge-skill levels by the client and adaption within therapy

Control group (n = 36)

No evaluation of challenge-skill levels by the client

Experimental group

74.11 (9.11)

24 females

12 males

Control group 75.17 (9.99)

21 females

15 males

Subjective Quality of life (Ikigai-9)

Health-related quality of life (EuroQol-5 Dimensions, Five Levels (EQ-5D-5L)

Flow State Scale for Occupational Tasks (FSSOT)

Flow scores were at high level (Score ranges 14–98) in both groups. Higher scores for the intervention group but not significantly different between the groups

Intervention group

Pre

Post

Change score

Control group

Pre

Post

Change score

Effect size between the groups

FSSOT Mean (SD)

79.56 (10.9)

81.09 (10.54)

1.66 (10.15)

FSSOT Mean (SD)

75.47 (15.32)

78.11 (14.15)

2.64 (10.33)

-0.09

  1. CFS Core Flow Scale, CPT-X continuous performance test X task, C-NMES conventional neuromuscular electrical stimulation, ERQ emotion regulation questionnaire, EQ-5D-5L EuroQol-5 dimensions, five levels, FSS Flow State Scale, FSSOT Flow State Scale for occupational tasks, GAD-7 generalized anxiety disorder scale, HISDS head injury semantic differential scale, N number, nr not reported, MG-NMES neuromuscular electrical stimulation, FMA Fugl-Meyer assessment, MARS moss attention rating scale, MBI modified Barthel Index, Ikigai-9 subjective quality of life measurement, PANAS-20 positive affect and negative affect scale, PASAT paced auditory serial addition test, PHQ-9 patient health questionnaire-9, RAVLT Ray’s auditory verbal learning test, RCT randomized controlled trial, SF-8 short-form health survey for general health, SFS Short Flow Scale, SD standard deviation, SDMT symbol digit modalities test, TMT trail making test, SWLS satisfaction with life scale, UTAUT unified theory of acceptance and use of technology