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