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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